Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

Objectives: The primary goal of evaluation for acute‐onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute‐onset headache. Methods: This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results: SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions: CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute‐onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444–451 © 2010 by the Society for Academic Emergency Medicine     

Attitudes and Judgment of Emergency Physicians in the Management of Patients with Acute Headache

OBJECTIVES: There is little evidence guiding physicians in the evaluation of acute headache to rule out nontraumatic subarachnoid hemorrhage (SAH). The authors assessed emergency physicians in: 1) their pretest accuracy for predicting SAH, 2) their comfort with not ordering either head computed tomography (CT) or lumbar puncture (LP) in patients with acute headache, and 3) their comfort with not ordering head CT before performing LP in patients with acute headache. METHODS: This two-and-a-half-year prospective cohort study was conducted in three tertiary care university emergency departments with 51 emergency physicians. Consecutive patients more than 15 years of age with a nontraumatic, acute headache (onset to peak headache less than one hour) and normal results on neurologic examination were enrolled. Patients known to have cerebrospinal fluid shunt, aneurysm, or brain neoplasm, and patients with recurrent headaches of the same intensity/character as their current headache were excluded. Physicians recorded their pretest probability for SAH and their comfort with performing either no tests or an LP without first obtaining head CT. RESULTS: The authors enrolled 747 patients (mean age 42.8 years; 60.1% female; 77.0% their worst headache; 83.4% had CT and/or LP), including 50 (6.7%) with SAHs. Physicians reported being "uncomfortable" or "very uncomfortable" with performing no test in 75.4% of cases and being "uncomfortable" or "very uncomfortable" with performing LP without CT in 49.6% of cases. The area under the receiver operating characteristic (ROC) curve for SAH was 0.85 (95% CI = 0.80 to 0.91). CONCLUSIONS: Physicians were able to moderately discriminate SAH from other causes of headache before diagnostic testing.     

Prevalence of Herniation and Intracranial Shift on Cranial Tomography in Patients With Subarachnoid Hemorrhage and a Normal Neurologic Examination

Objectives: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. Methods: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift. Results: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report. Conclusions: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH. ACADEMIC EMERGENCY MEDICINE 2010; 17:423–428 © 2010 by the Society for Academic Emergency Medicine     

Diagnostic criteria for acute headache attributed to ischemic stroke and for sentinel headache before ischemic stroke

BackgroundDefining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache.MethodsThis prospective case-control study included 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency room in both groups of patients. All headaches were diagnosed according to the ICHD-3. We tabulated the onset of different headaches before a first-ever ischemic stroke and at the time of onset of stroke. We divided them into three groups: a new type of headache, the previous headache with altered characteristics and previous unaltered headaches. The same was done for headaches in control patients within one week before admission to the hospital and at the time of entry. These data were used to create and test diagnostic criteria for acute headache attributed to stroke and sentinel headache.ResultsOur previous studies showed that headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients, and 81 (14.7%) patients had sentinel headache within the last week before a stroke. Only 60% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-3. Therefore, we proposed alternative criteria with a sensitivity of 100% and specificity of 97%. Besides, we developed diagnostic criteria for sentinel headache for the first time with a specificity of 98% and a sensitivity of 100%.ConclusionsWe suggest alternative diagnostic criteria for acute headache attributed to ischemic stroke and new diagnostic criteria for sentinel headache with high sensitivity and specificity.     

Computed Tomographic Angiography for the Evaluation of Aneurysmal Subarachnoid Hemorrhage

Objectives: Computed tomography (CT) followed by lumbar puncture (LP) is currently the criterion standard for diagnosing subarachnoid hemorrhage (SAH) in the emergency department (ED); however, this is based on studies involving a limited number of patients. The authors sought to assess the ability of CT angiography (CTA), a new diagnostic modality, in conjunction with CT/LP to detect SAH. Methods: Consecutive patients presenting to the ED with symptoms concerning for SAH were approached. All patients had an intravenous catheter placed and underwent a noncontrast head CT followed by CTA. Patients whose CT did not reveal evidence of SAH or other pathology underwent LP in the ED. CTAs were read within 24 hours by a neuroradiologist blinded to the patient's history. Results: A total of 131 patients were approached, 116 were enrolled, and 106 completed the study. In six of 116 patients (5.1%), aneurysm was found on CTA with normal CT and positive findings on LP; three had a positive CTA with normal CT and LP findings (one of which had a negative cerebral angiogram), and there was one false‐positive CTA. Follow‐up of all 131 patients showed no previously undiagnosed intracranial pathology. In this patient population, 4.3% (5/116) were ultimately found to have an SAH and/or aneurysm. Conclusions: In this pilot study, CTA was found to be useful in the detection of cerebral aneurysms and may be useful in the diagnosis of aneurysmal SAH. A larger multicenter study would be useful to confirm these results.     

The Child With Headache in a Pediatric Emergency Department

Objectives.— To investigate clinical features of a pediatric population presenting with headache to a pediatric emergency department (ED) and to identify headache characteristics which are more likely associated with serious, life‐threatening conditions in distinction from headaches due to more benign processes. Background.— Although headache is a common problem in children visiting a pediatric ED, a few studies thus far have attempted to identify the clinical characteristics most likely associated with suspected life‐threatening disease. Methods.— A retrospective chart review of all consecutive patients who presented with a chief complaint of headache at ED over a 1‐year period was conducted. Etiologies were classified according to the International Headache Society diagnostic criteria 2nd edition. Results.— Four hundred and thirty‐two children (0.8% of the total number of visits) aged from 2 to 18 years (mean age 8.9 years) were enrolled in our study. There were 228 boys (53%) and 204 girls (47%). School‐age group was the most represented (66%). The most common cause of headache was upper respiratory tract infections (19.2%). The remaining majority of non‐life‐threatening headache included migraine (18.5%), posttraumatic headache (5.5%), tension‐type headache (4.6%). Serious life‐threatening intracranial disorders (4.1%) included meningitis (1.6%), acute hydrocephalus (0.9%), tumors (0.7%). We found several clinical clues which demonstrated a statistically significant correlation with dangerous conditions: pre‐school age, recent onset of pain, occipital location, and child's inability to describe the quality of pain and objective neurological signs. Conclusions.— Differential diagnosis between primary and secondary headaches can be very difficult, especially in an ED setting. The majority of headaches are secondary to respiratory infectious diseases and minor head trauma. Our data allowed us to identify clinical features useful to recognize intracranial life‐threatening conditions.     

Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: Are fifth generation CT scanners better at identifying subarachnoid hemorrhage?

This study sought to determine the sensitivity and specificity of modern computed tomography (CT) scans for the diagnosis of subarachnoid hemorrhage (SAH). No studies have been done recently with fifth generation CT scanners to look at the diagnosis of SAH. A retrospective chart review was done of Emergency Department (ED), laboratory, and hospital records at Pitt County Memorial Hospital in Greenville, North Carolina over 1 year from January 1, 2002 to December 31, 2002. Patients presented with headache and had a CT scan of the head with a fifth generation multi-detector CT scanner followed by a lumbar puncture (LP) to rule out SAH. There were 177 patients who presented to the ED with headache and went on to have a CT scan and an LP to rule out SAH. No patients who had a negative CT were found to have a subarachoid hemorrhage. It is concluded that fifth generation CT scanners are probably more sensitive than earlier scanners at detecting SAH.     

Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta‐analysis and Systematic Review of the Literature

Objectives: Neurogenic inflammation is thought to play a role in the development and perpetuation of migraine headache. The emergency department (ED) administration of dexamethasone in addition to standard antimigraine therapy has been used to decrease the incidence of recurrent headaches at 24 to 72 hours following evaluation. This systematic review details the completed trials that have evaluated the use of dexamethasone in this role. Methods: The authors searched MEDLINE, EMBASE, CINAHL, LILACS, recent emergency medicine scientific abstracts, and several prepublication trial registries for potential investigations related to the research question. The authors included studies that incorporated randomized, double‐blind, placebo‐controlled methodology and that were performed in the ED. A fixed‐effects and random‐effects model was used to obtain summary risk ratios (RRs) and 95% confidence intervals (CIs) for the self‐reported outcome of moderate or severe headache on follow‐up evaluation. Results: A pooled analysis of seven trials involving 742 patients suggests a modest but significant benefit when dexamethasone is added to standard antimigraine therapy to reduce the rate of patients with moderate or severe headache on 24‐ to 72‐hour follow‐up evaluation (RR = 0.87, 95% CI = 0.80 to 0.95; absolute risk reduction = 9.7%). The treatment of 1,000 patients with acute migraine headache using dexamethasone in addition to standard antimigraine therapy would be expected to prevent 97 patients from experiencing the outcome of moderate or severe headache at 24 to 72 hours after ED evaluation. The sensitivity analysis yielded similar results with sequential trial elimination, indicating that no single trial was responsible for the overall result. Adverse effects related to the administration of a single dose of dexamethasone were infrequent, mild, and transient. Conclusions: These results suggest that dexamethasone is efficacious in preventing headache recurrence and safe when added to standard treatment for the management of acute migraine headache in the ED.     

Sensitivity of newer-generation computed tomography scanners for subarachnoid hemorrhage: a Bayesian analysis

Background

Subarachnoid hemorrhage (SAH) is a life-threatening condition considered in patients presenting to the emergency department (ED) with acute and severe-onset headache. Currently, the practice pattern for suspected SAH is to perform a non-contrasted computed tomography (CT) scan of the head, followed by lumbar puncture (LP) if the CT is negative. Newer-generation 16-slice CT scanners have been shown in one study to be very sensitive for SAH.

Objective

We sought to validate these findings at our institution by retrospectively analyzing the sensitivity of our 16-slice or better CT scanner and performing a bayesian analysis with the results.

Methods

We utilized ED electronic medical records and the Department of Neurosurgery research database to search for patients admitted from the ED with a diagnosis of SAH from January 1, 2005 to December 31, 2008. We found a total of 134 patients admitted with SAH during this time frame.

Results

Average age was 53.8 years; 62% were female. Presenting complaint was headache in 57%, paresthesia or weakness in 7%, unresponsive in 10%, confusion or altered mental status in 5%, and “other” in 10%. Sensitivity of 16-slice or better CT scanner in our study was 131/134, or 97.8% (95% confidence interval 93.1–99.4%). No patient with a negative CT had a lesion requiring intervention.

Conclusion

Our study confirms the high sensitivity of 16-slice or better CT scanners for SAH. This calls into question the need for LP after negative head CT when 16-slice CT or better is used.     

Clues in the Differential Diagnosis of Primary vs Secondary Cough,Exercise, and Sexual Headaches

Activity‐related headaches can be provoked by Valsalva maneuvers (“cough headache”), prolonged exercise (“exertional headache”) and sexual excitation (“sexual headache”). These entities are a challenging diagnostic problem as can be primary or secondary and the etiologies for secondary cases differ depending on the headache type. In this paper we review the clinical clues which help us in the differential diagnosis of patients consulting due to activity‐related headaches. Cough headache is the most common in terms of consultation. Primary cough headache should be suspected in patients older than 50 years, if pain does not predominate in the occipital area, if pain lasts seconds, when there are no other symptoms/signs and if indomethacin relieves the headache attacks. Almost half of cough headaches are secondary, usually to a Chiari type I malformation. Secondary cough headache should be suspected in young people, when pain is occipital and lasts longer than one minute, and especially if there are other symptoms/signs and if there is no response to indomethacin. Every patient with cough headache needs cranio‐cervical MRI. Primary exercise/sexual headaches are more common than secondary, which should be suspected in women especially with one episode, when there are other symptoms/signs, in people older than 40 and if the headache lasts longer than 24 hours. These patients must have quickly a CT and then brain MRI with MRA or an angioCT to exclude space‐occupying lesions or subarachnoid hemorrhage.     

Chronic post-traumatic headaches classified and compared with natural headaches

This study sought to determine whether chronic post-traumatic headaches are different from or identical to the naturally occurring headaches. The chronic post-traumatic headaches of 48 patients were classified, as if they were natural headaches, by the diagnostic criteria of the International Headache Society. Thirty-six patients' headaches (75%) were chronic tension-type headache, 10 (21%) were migraine without aura , and 2 (4%) were unclassifiable. The characteristics and accompaniments of the headaches within each diagnostic group were then compared to those in a control group with natural headaches of the same type. No notable differences between the post-traumatic and control groups were found. Hence, chronic post-traumatic headaches have no special features, but are symptomatically identical to either chronic tension-type headache or migraine without aura (in this series of patients). This identity suggests that post-traumatic headaches are generated by the same processes causing the natural headaches, not by intracranial derangement from head blows or jolts.     

An exploratory study of IV metoclopramide + diphenhydramine for acute post-traumatic headache

Background

Headache is a frequent complaint among the 1.4 million patients who present to US emergency departments (ED) annually following trauma to the head. There are no evidence-based treatments of acute post-traumatic headache.

Etiology and distribution of headaches in two Brazilian primary care units

OBJECTIVES: To determine (a) which patients seek primary care services with a complaint of headache, (b) the percentages of the various types of headache in this population, and (c) the impact of the care provided to these patients on the basic health care network. BACKGROUND: Headache is one of the most frequent symptoms reported in medical practice, resulting in significant medical services costs and loss of patient productivity, as well as reduced quality of life. METHODS: A prospective study was conducted in two towns (Ribeir?o Preto and S?o Carlos) in the State of S?o Paulo, Brazil. The participants in the study consisted of 6006 patients (52.4% women) with highly varied acute symptoms. The patients ranged in age from 14 to 98 years. RESULTS: Headache as the main complaint was reported by 561 (9.3%) of the patients considered, with 312 (55.6%) of those patients presenting with primary headache, 221 (39.4%) with headaches secondary to systemic disorders, and 28 (5.0%) with headaches secondary to neurological disorders. Migraine, the most prevalent primary headache, accounted for 45.1% of patients reporting headache as the single symptom. The most frequent etiologies of headaches secondary to systemic disorders were fever, acute hypertension, and sinusitis. The most frequent headaches secondary to neurological disorders were posttraumatic headaches, headaches secondary to cervical disease, and expansive intracranial processes. Of the 26 cases of drug abuse, 20 were secondary to alcohol (hangover). Headaches secondary to systemic disorders were more frequent in the extreme age ranges. CONCLUSIONS: Headache is a very frequent symptom among patients seen at primary health care units and should be considered a public health problem. The dissemination of the diagnostic criteria of the International Headache Society among primary health care physicians is urgently needed in order to avoid the repeated return of patients or their referral to more differentiated emergency units, which overburden an already insufficient health care network.     

Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.     

Headaches precipitated by cough,prolonged exercise or sexual activity: a prospective etiological and clinical study

Headaches provoked by cough, prolonged physical exercise and sexual activity have not been studied prospectively, clinically and neuroradiologically. Our aim was to delimitate characteristics, etiology, response to treatment and neuroradiological diagnostic protocol of those patients who consult to a general Neurological Department because of provoked headache. Those patients who consulted due to provoked headaches between 1996 and 2006 were interviewed in depth and followed-up for at least 1 year. Neuroradiological protocol included cranio-cervical MRI for all patients with cough headache and dynamic cerebrospinal functional MRI in secondary cough headache cases. In patients with headache provoked by prolonged physical exercise or/and sexual activity cranial neuroimaging (CT and/or MRI) was performed and, in case of suspicion of subarachnoid bleeding, angioMRI and/or lumbar tap were carried out. A total of 6,412 patients consulted due to headache during the 10 years of the study. The number of patients who had consulted due to any of these headaches is 97 (1.5% of all headaches). Diagnostic distribution was as follows: 68 patients (70.1%) consulted due to cough headache, 11 (11.3%) due to exertional headache and 18 (18.6%) due to sexual headache. A total of 28 patients (41.2%) out of 68 were diagnosed of primary cough headache, while the remaining 40 (58.8%) had secondary cough headache, always due to structural lesions in the posterior fossa, which in most cases was a Chiari type I malformation. In seven patients, cough headache was precipitated by treatment with angiotensin-converting enzyme inhibitors. As compared to the primary variety, secondary cough headache began earlier (average 40 vs. 60 years old), was located posteriorly, lasted longer (5 years vs. 11 months), was associated with posterior fossa symptoms/signs and did not respond to indomethacin. All those patients showed difficulties in the cerebrospinal fluid circulation in the foramen magnum region in the dynamic MRI study and preoperative plateau waves, which disappeared after posterior fossa reconstruction. The mean age at onset for primary headaches provoked by physical exercise and sexual activity began at the same age (40 years old), shared clinical characteristics (bilateral, pulsating) and responded to beta-blockers. Contrary to cough headache, secondary cases are rare and the most frequent etiology was subarachnoid bleeding. In conclusion, these conditions account for a low proportion of headache consultations. These data show the total separation between cough headache versus headache due to physical exercise and sexual activity, confirm that these two latter headaches are clinical variants of the same entity and illustrate the clinical differences between the primary and secondary provoked headaches.     

Clinical and Angiographic Features of Thunderclap Headache

Thunderclap headache is an acute high intensity headache similar to that seen in the setting of ruptured saccular aneurysm. We report four patients without subarachnoid hemorrhage who presented with thunderclap headache. Three patients had transient neurologic signs or symptoms. Cerebral angiography revealed diffuse segmental intracerebral arterial vasoconstriction which was reversible in the one patient in whom angiography was repeated. The headaches resolved spontaneously in all cases and after 1 week did not recur. These cases highlight the specific clinical and angiographic features and the self-limited course of patients with thunderclap headache and suggest that thunderclap headache may represent a unique headache category. On the basis of these cases and others reported in the literature, we propose diagnostic criteria for thunderclap headache.     

Headache in acute stroke. A prospective study in the first 8 days

We aimed to describe and classify headaches associated with acute stroke, by interviewing patients consecutively admitted to a stroke unit using a validated headache questionnaire and the International Classification of Headache Disorders of the International Headache Society (IHS). One hundred and twenty-four patients (61% ischaemic and 39% haemorrhagic stroke) reported headache. Headaches started mostly on the day of stroke, were more often continuous, pressure-type, bilateral and located in the anterior region, were increased by movement and by cough and lasted for a mean of 3.8 days. Tension-type was the most frequent type of headache. Eleven per cent of headaches could not be classified using the criteria of the IHS. Previous primary headache was documented in 71 patients. The presence of nausea/vomiting due to acute stroke can confound headache classification using the IHS criteria. In up to half of the patients, headache seems to be a reactivation of previous primary headache.     

Chronic post-traumatic headache--a clinical analysis in relation to the International Headache Classification 2nd Edition

The clinical presentation of chronic post-traumatic headache in 53 patients from a highly specialized headache clinic was analysed and classified according to the diagnostic criteria of the primary headaches in The International Headache Classification 2nd Edition, and compared with the 1st Edition. All patients fulfilled the criteria for both editions indicating that the restrictions in the 2nd Edition have no major influence on the prevalence in specialized clinics. We found the phenomenology to be very heterogeneous, but the vast majority (77%) of patients presented with headache resembling chronic tension-type headache, either as the only manifestation or in combination with migraine symptoms. For the first time episodic tension-type headache is described as occurring after head trauma. The prevalence of coexisting analgesic overuse was 42% and the treatment outcome for these patients was just as favourable as in primary headaches, whereas the time-consuming multidisciplinary treatment demonstrated only very modest results.     

Findings of Chronic Sinusitis on Brain Computed Tomography Are Not Associated with Acute Headaches

Background

Headache is a common complaint in emergency department (ED) patients. Nearly 15% of ED headache patients will have brain computed tomography (CT) done. One frequent finding on these scans is “chronic sinusitis.” Assuming that “chronic sinusitis” is the cause of the patient's headache is a potential source of mis-diagnosis.

Study Objective

We hypothesized that CT findings of chronic sinusitis occur with equal frequency in patients with atraumatic headache as in control patients with minor head injury.

Methods

This is a retrospective, single-center medical record review of consecutive discharged patients who received noncontrast head CT scans in an urban ED for either minor closed head injury or atraumatic headache. Each patient's head CT radiologic report was reviewed for findings of sinusitis and classified as chronic sinusitis, indeterminate for sinusitis, air-fluid levels, or no findings of sinusitis.

Results

We enrolled 500 patients (234 in the atraumatic headache group, 266 in the minor head injury group). The two groups were similar except that more women were enrolled in the atraumatic headache group. CT findings of chronic sinusitis in the atraumatic headache group (22.2%) and the minor head injury group (17.7%; difference 4.5%; 95% confidence interval of −2.5–11.6%).

Conclusion

Prevalence of CT findings of sinusitis in ED patients with atraumatic headaches and mild head injury are similar. This strongly suggests that CT findings of chronic sinusitis in patients with atraumatic headache may be incidental, and are rarely the cause of a patient's acute headache.