How to Diagnose Acute HeadacheAcute Headache accounts for about 3-8% of emergency room attendances, and for about 3% of emergency admissions to an acute medical ward. As a neurologist working in an acute general hospital I would see about 1-2 acute headache cases each week - about 100 per annum. Almost everyone will experience head pain at some point in their lives, as evidenced by studies of headache epidemiology. Epidemiology is the who, what and where of medical practice. Here's a guide on how make a headache diagnosis and sort out the serious from non-serious causes of acute headache. It is based upon a lecture on headache I gave to a Royal College of Physicians of Edinburgh Up-Date Meeting in 2008, 2009, and remains current for 2010. There are 5 steps to successful headache management:
Step 1: Which acute headache category is it?When assessing the person with a headache emergency, it is important to realise that there are about 5 different categories of headache that present as an emergency.
These 5 categories form the basis of your acute headache differential diagnosis. Once you have worked out which category you are in you are in a position to start your clinical neurological examination. Step 2: Perform a Quick Neurological ExaminationI have devised a quick screening examination - Forbes Quick Neurological Examination.In addition to the actions mentioned in the video, look for meningism and check for a Horner's Syndrome. It goes without saying that you have recored the vital signs of temperature, pulse rate, blood pressure and respiratory rate. If there is altered consciousness a Glasgow Coma Scale should be recorded too. Step 3: Make a Differential DiagnosisThe differential diagnosis is a term to describe the range of likely diagnoses that could explain the symptoms experienced by the headache sufferer.The differential diagnosis for each of the 5 categories in Step 1 is slightly different. Here are the options with the most common first, least common last:
Step 4: Arrange Appropriate InvestigationsMost people with an acute headache that is not obviously a migraine headache, systemic illness headache, temporal arteritis nor cervicogenic headache will require a brain scan.A CT Brain Scan is usually sufficient, but there are some pitfalls for the unwary. There may be rare cases where an MRI Brain Scan is preferable, but MRI needs to be used intelligently, as it is a complex test to set up and perform. About 30% of people with acute headache will require a lumbar puncture procedure. This is usually to rule out haemorrhage by testing for xanthochromia, but is also needed to rule out high or low intracranial pressure and the presence or absence of infection. Detailed knowledge of a Lumbar Puncture Procedure is a core skill for any doctor practising emergency medicine. A poorly performed LP can be a cause of significant patient discomfort and could yield misleading results. Step 5: Make a Final Headache Diagnosis and Complete TreatmentBased upon data from my own practice, the most common emergency headache diagnoses are primary headache disorders, such as migraine. About 25% of cases had a non-serious secondary headache associated with infection - so callled systemic illness headache.More detail on headache diagnosis in a typical hospital population is appended. Only 6% of acute headaches that were admitted to hospital had a life-threatening cause. The treatment will depend upon your final headache diagnosis.
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