Bibliographic Source(s)

• Edlow JA Panagos PD Godwin SA Thomas TL Decker WW American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-36. [91 references] PubMed

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med 2002 Jan;39(1):108-22. [49 references]

Guideline Category

Diagnosis
Evaluation
Management
Risk Assessment

Intended Users

Physicians

Guideline Objective(s)

• To update the 2002 American College of Emergency Physicians clinical policy on the evaluation and management of patients presenting to the emergency department with acute headache
• To derive evidence-based recommendations to help clinicians answer the following 5 critical questions:
  1. Does a response to therapy predict the etiology of an acute headache?
  2. Which patients with headache require neuroimaging in the emergency department (ED)?
  3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal?
  4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?
  5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset severe headache who has negative findings in both CT and lumbar puncture?

Target Population

Adult patients presenting to the emergency department (ED) with acute nontraumatic headache

Note: This guideline is not intended to address the care of pediatric patients or the care of patients with trauma-related headaches.

Interventions and Practices Considered

1. Medical history and physical examination including neurologic examination
2. Assessment of pain response to therapy (not recommended as the sole diagnostic indicator of the underlying etiology of an acute headache)
3. Lumbar puncture with cerebrospinal fluid (CSF) analysis (with and without a neuroimaging study)
4. Neuroimaging: head computed tomography (CT) scan with or without contrast; CT angiography; magnetic resonance imaging (MRI)
5. Risk assessment for lumbar puncture
6. Emergency Department discharge and follow-up

Major Outcomes Considered

• Accuracy of response to analgesic for determining serious secondary cause of headache
• Sensitivity and predictive value of diagnostic neuroimaging for detecting brain pathology especially subarachnoid hemorrhage
• Safety of performing a lumbar puncture (LP) contraindications to LP and risk of adverse outcomes with LP
• Risk of herniation
• Incidence of subarachnoid hemorrhage or sudden death in patients with normal computed tomography (CT) and LP

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Multiple searches of MEDLINE and the Cochrane database were performed. Specific key words/phrases used in the searches are identified under each critical question. To update the 2002 American College of Emergency Physicians (ACEP) policy which used literature up to December 1999 all searches were limited to English-language sources human studies adults and years January 2000 to August 2006. Additional articles were reviewed from the bibliography of articles cited and from published textbooks and review articles. Subcommittee members supplied articles from their own files and more recent articles identified during the expert review process were also included.

See the original guideline document for words/phrases for literature searches associated with each clinical question reproduced in the "Guideline Objectives" field.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Strength of Evidence

Literature Classification Schema^

^Some designs (e.g. surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing >2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

***Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

This clinical policy was created after careful review and critical analysis of the medical literature.

All articles used in the formulation of this clinical policy were graded by at least 2 subcommittee members for strength of evidence and classified by the subcommittee members into 3 classes of evidence on the basis of the design of the study with design 1 representing the strongest evidence and design 3 representing the weakest evidence for therapeutic diagnostic and prognostic clinical reports respectively (see the "Rating Scheme for the Strength of Evidence" field). Articles were then graded on 6 dimensions thought to be most relevant to the development of a clinical guideline: blinded versus nonblinded outcome assessment blinded or randomized allocation direct or indirect outcome measures (reliability and validity) biases (e.g. selection detection transfer) external validity (i.e. generalizability) and sufficient sample size. Articles received a final grade (Class I II III) on the basis of a predetermined formula taking into account design and quality of study (see the "Rating Scheme for the Strength of Evidence" field). Articles with fatal flaws were given an "X" grade and not used in formulating recommendations in this policy. Evidence grading was done with respect to the specific data being extracted and the specific critical question being reviewed. Thus the level of evidence for any one study may vary according to the question and it is possible for a single article to receive different levels of grading as different critical questions are answered. Question-specific level of evidence grading may be found in the Evidentiary Table included at the end of original guideline document.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The panel used the American College of Emergency Physicians (ACEP) clinical policy development process including expert review and is based on the existing literature; when literature was not available consensus of emergency physicians was used.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e. based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e. based on strength of evidence Class II studies that directly address the issue decision analysis that directly addresses the issue or strong consensus of strength of evidence Class III studies).

Level C recommendations. Other strategies for patient management that are based on preliminary inconclusive or conflicting evidence or in the absence of any published literature based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results uncertainty about effect magnitude and consequences strength of prior beliefs and publication bias among others might lead to such a downgrading of recommendations.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Expert review comments were received from individual emergency physicians and from individual members of the American Headache Society and the Society for Academic Emergency Medicine. Their responses were used to further refine and enhance this policy; however their responses do not imply endorsement of this clinical policy. This document was also reviewed by the Joint Guidelines Committee (JGC) of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) however this review does not constitute an endorsement or approval of the document its content or conclusions by the JGC the AANS or the CNS.

Major Recommendations

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the Major Recommendations.

1. Does a response to therapy predict the etiology of an acute headache?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. None specified.

   Level C recommendations. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

2. Which patients with headache require neuroimaging in the Emergency Department (ED)?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations.

   1. Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (e.g. focal deficit altered mental status altered cognitive function) should undergo emergent* noncontrast head computed tomography (CT).
   2. Patients presenting with new sudden-onset severe headache should undergo an emergent* head CT.
   3. Human immunodeficiency virus (HIV)-positive patients with a new type of headache should be considered for an emergent*neuroimaging study.

   Level C recommendations. Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination should be considered for an urgent** neuroimaging study.

   *Emergent studies are those essential for a timely decision regarding potentially life-threatening or severely disabling entities.

3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain CT scans are interpreted as normal?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. In patients presenting to the ED with sudden-onset severe headache and a negative noncontrast head CT scan result lumbar puncture should be performed to rule out subarachnoid hemorrhage.

   Level C recommendations. None specified.

4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. None specified.

   Level C recommendations.

   1. Adult patients with headache and exhibiting signs of increased intracranial pressure (e.g. papilledema absent venous pulsations on funduscopic examination altered mental status focal neurologic deficits signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.
   2. In the absence of clinical findings suggestive of increased intracranial pressure a lumbar puncture can be performed without obtaining a neuroimaging study. (Note: A lumbar puncture does not assess for all causes of a sudden severe headache).

5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset severe headache who has negative findings in both CT and lumbar puncture?

   Patient Management Recommendations

   Level A recommendations. None specified.

   Level B recommendations. Patients with a sudden-onset severe headache who have negative findings on a head CT normal opening pressure and negative findings in cerebrospinal fluid (CSF) analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended.

   Level C recommendations. None specified.

Definitions:

Strength of Evidence

Literature Classification Schema^

^Some designs (e.g. surveys) will not fit this schema and should be assessed individually.

*Objective is to measure therapeutic efficacy comparing >2 interventions.

**Objective is to determine the sensitivity and specificity of diagnostic tests.

***Objective is to predict outcome including mortality and morbidity.

Approach to Downgrading Strength of Evidence*

*See "Description of Methods Used to Analyze the Evidence" field for more information.

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e. based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e. based on strength of evidence Class II studies that directly address the issue decision analysis that directly addresses the issue or strong consensus of strength of evidence Class III studies).

Level C recommendations. Other strategies for patient management that are based on preliminary inconclusive or conflicting evidence or in the absence of any published literature based on panel consensus.

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results uncertainty about effect magnitude and consequences strength of prior beliefs and publication bias among others might lead to such a downgrading of recommendations.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Potential Benefits

Safe and timely evaluation and management of patients presenting to the emergency department (ED) with acute nontraumatic headache.

Potential Harms

Diagnostic procedures can result in adverse effects. For example lumbar puncture can result in herniation.

Qualifying Statements

• This policy is not intended to be a complete manual on the evaluation and management of adult patients with acute headache but rather a focused examination of critical issues that have particular relevance to the current practice of emergency medicine.
• It is the goal of the Clinical Policies Committee to provide an evidence-based recommendation when the medical literature provides enough quality information to answer a critical question. When the medical literature does not contain enough quality information to answer a critical question the members of the Clinical Policies Committee believe that it is equally important to alert emergency physicians to this fact.
• Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. The American College of Emergency Physicians (ACEP) clearly recognizes the importance of the individual physician's judgment. Rather this guideline defines for the physician those strategies for which medical literature exists to provide support for answers to the crucial questions addressed in this policy.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better

IOM Domain

Effectiveness
Safety
Timeliness

Bibliographic Source(s)

• Edlow JA Panagos PD Godwin SA Thomas TL Decker WW American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-36. [91 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American College of Emergency Physicians

Guideline Committee

Clinical Policies Subcommittee (Writing Committee)

Composition of Group that Authored the Guideline

Clinical Policies Subcommittee (Writing Committee): Jonathan A. Edlow MD (Chair); Peter D. Panagos MD; Steven A. Godwin MD; Tamara L. Thomas MD; Wyatt W. Decker MD

American College of Emergency Physicians Clinical Policies Committee (Oversight Committee): Andy S. Jagoda MD (Chair 2003-2006 Co-Chair 2006-2007); Wyatt W. Decker MD (Co-Chair 2006-2007 Chair 2007-2008); Deborah B. Diercks MD; Barry M. Diner MD (Methodologist); Jonathan A. Edlow MD; Francis M. Fesmire MD; John T. Finnell II MD MSc (Liaison for Emergency Medical Informatics Section 2004-2006); Steven A. Godwin MD; Sigrid A. Hahn MD; John M. Howell MD; J. Stephen Huff MD; Eric J. Lavonas MD; Thomas W. Lukens MD PhD; Donna L. Mason RN MS CEN (ENA Representative 2004-2006); Edward Melnick MD (EMRA Representative 2007-2008); Anthony M. Napoli MD (EMRA Representative 2004-2006); Devorah Nazarian MD; AnnMarie Papa RN MSN CEN FAEN (ENA Representative 2007-2008); Jim Richmann RN BS MA(c) CEN (ENA Representative 2006-2007); Scott M. Silvers MD; Edward P. Sloan MD MPH; Molly E. W. Thiessen MD (EMRA Representative 2006-2008); Robert L. Wears MD MS (Methodologist); Stephen J. Wolf MD; Cherri D. Hobgood MD (Board Liaison 2004-2006); David C. Seaberg MD CPE (Board Liaison 2006-2008); Rhonda R. Whitson RHIA Staff Liaison Clinical Policies Committee and Subcommittees

Financial Disclosures/Conflicts of Interest

Relevant industry relationships of subcommittee members: There were no relevant industry relationships disclosed by the subcommittee members.

Relevant industry relationships are those relationships with companies associated with products or services that significantly impact the specific aspect of disease addressed in the critical question.

Endorser(s)

Emergency Nurses Association - Medical Specialty Society

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American College of Emergency Physicians (ACEP). Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med 2002 Jan;39(1):108-22. [49 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American College of Emergency Physicians Web site.

Print copies: Available from the American College of Emergency Physicians P.O. Box 619911 Dallas TX 75261-9911 or call toll free: (800) 798-1822.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on January 29 2003. The information was verified by the guideline developer on March 13 2003. This summary was updated by ECRI Institute on November 12 2008. The updated information was verified by the guideline developer on December 5 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. For more information please refer to the American College of Emergency Physicians (ACEP) Web site.

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