New guidelines for acute headaches: Here’s how your practice will change
New approaches assess whether a patient’s life is in danger
When a 23-year-old man driving a sports utility vehicle was rear-ended, the accident didn’t seem serious: The windshield was intact, and there was no interior damage to the driver’s vehicle. The man did not lose consciousness or sustain an obvious head injury, and he wasn’t treated by emergency medical services at the scene.
Two weeks later, he came to the ED complaining of a headache and altered vision. The man told the triage nurse that the headache started a few hours after the accident and was intermittent for several days, but it now was persistent, according to the case study provided by Steven D. Glow, RN, MSN, FNP, nursing faculty at Salish Kootenai College in Pablo, MT, and an ED nurse at Community Medical Center in Missoula, MT.
Based on a pain scale of 1 to 10, the patient said that the pain ranged from a score of 3 to 7. The patient was triaged as emergent because he had a headache and neurological symptoms, and he was promptly seen by the ED physician. The screening neurological exam revealed a focal neurological deficit, and a noncontrast computed tomography (CT) scan was ordered. "Unfortunately, a large intracranial mass was detected," says Glow. "The patient was admitted to neurology, and [magnetic resonance imaging] was ordered for the next day."
In this case, the rapid evaluation and diagnosis enabled the patient to access appropriate specialist care in a timely manner, says Glow. If these interventions were not done, and the patient somehow slipped through the cracks, treatment would have been delayed, he adds. The above anecdote underscores the importance of appropriate triage and management of acute headaches, emphasizes Glow. Potentially life-threatening headaches may be overlooked if diagnostic guidelines are not followed, he adds.
New guidelines from the Dallas-based American College of Emergency Physicians (ACEP) give current approaches for management of acute headaches but reveal a lack of evidence-based research for this patient population, says Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, clinical nurse specialist for the ED at Northwestern Memorial Hospital in Chicago. (For ordering information, see "Sources and resource" at the end of this article.)
She notes that the ACEP guidelines contain no Level A recommendations, which indicate a high degree of clinical certainty, and that most are Level C, which are based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, she adds.1 "The recommendations, then, reflect the practice most of us have been experiencing in our own EDs," concludes Steinmann. "We obviously still have much to learn about this common entity."
Here are key points of the ACEP recommendations with suggestions for how to change your practice:
• You should give a screening neurological exam at triage to all patients with headaches. Patients who present with an abnormal neurologic exam are at higher risk of having life-threatening pathology, Steinmann says. The ACEP recommendations indicate there is not enough research to make Level A recommendations for diagnostic testing for headache patients, says Glow. Evidence supports only one Level B recommendation, for emergent CT scan when headache is combined with an abnormal neurological exam, he adds. "The implication is that the triage nurse should perform at least a screening neurological exam on all patients with headache," he says. (To learn how to perform a simple neurological exam at triage, see "Save lives with a rapid neuro exam," in ED Nursing, July 2001, p. 120.)
If there is an abnormal neurological finding, the patient should be classified as emergent, Glow emphasizes. This classification is consistent with the Simple Triage and Rapid Treatment (START) system developed by Hoag Hospital and the Newport Beach (CA) Fire Department, he adds. That system assigns all patients who cannot follow simple commands to the "red" immediate category.
• Patients with signs of increased intracranial pressure and/or an abnormal neurological exam should undergo neuroimaging before having a lumbar puncture, secondary to the risk of herniation. There is now a clear set of criteria to determine which patients should undergo a neuroimaging study prior to a lumbar puncture, says Glow. The guidelines give the following criteria: adult patients with headaches exhibiting signs of increased intracranial pressure, including papilledema, without venous pulsations on funduscopic examination, altered mental status, or focal neurological deficits. "You may need to advocate for such testing prior to a lumbar puncture when patients meet the criteria," Glow notes. "This has the potential to protect both the patient and the physician."
Headache patients with a normal neurological exam, normal mental status, a normal funduscopic exam, and no meningeal signs are the best candidates for lumbar puncture without a neuroimaging study, says Steinmann. Patients presenting with a headache and abnormal neurologic exam and patients presenting with an acute sudden-onset headache should receive emergent neuroimaging, she adds. HIV-positive patients and patients older than age 50 should be considered for an urgent neuroimaging study even without neurological abnormalities, if presenting with a new type of headache, Steinmann says.
• Patients who experience "thunderclap" headaches with negative CT and negative lumbar puncture do not need emergent angiography. These patients can be discharged to follow up with their primary care physician or neurologist, says Steinmann. Research does not suggest that this is a life-threatening presentation requiring this level of unscheduled diagnostics, she explains.
• Consider a patient’s need for diagnostic tests. You must continuously assess headache patients for signs of increased intracranial pressure, says Steinmann. However, the guidelines make it clear that specific diagnostic tests also are needed to determine the cause of an acute headache, says Glow. The current approach to determining if headaches are life-threatening or benign includes a history and physical exam, CT, and/or lumbar puncture, says Glow. "So you should consider the patient’s room assignment with these diagnostic options in mind," he advises. For example, a private room would be a better location to do a lumbar puncture, and some patients may require anxiolytic medications or conscious sedation prior to the procedure, he adds. You also should consider the patient’s need for sedation and the physician’s need for positioning assistance during the procedure when making nursing assignments, says Glow.
• Pharmacologic agents with an affinity to serotonin receptors are the preferred therapy in acute headache management. These include triptans, dihydroergotamine, prochlorperazine, and metoclopramide, says Steinmann. "However, the ability to relieve headache pain with pharmacologic agents does not exclude life-threatening pathology," she adds.
Reference
1. American College of Emergency Physicians. Clinical Policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med 2002; 39:108-122.
Sources and resource
For more information about management of acute headaches, contact:
• Steven D. Glow, RN, MSN, FNP, Nursing Faculty, Salish Kootenai College, P.O. Box 117, 52000 N. Highway 93, Pablo, MT 59855. Telephone: (406) 275-4922. E-mail: [email protected].
• Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, Emergency Department, Northwestern Memorial Hospital, Chicago, IL 60611. Telephone: (312) 926-7069. E-mail: [email protected].
The American College of Emergency Physicians Clinical Policy: Critical Issues in the Evaluation and Management of Patients Presenting to the Emergency Department with Acute Headache was published in the January 2002 issue of Annals of Emergency Medicine. Single copies are available for $5, including shipping. To order a copy, contact: ACEP Customer Service Department, 1125 Executive Circle, Irving, TX 75038-2522. Telephone: (800) 798-1822, ext. 6. Fax: (972) 580-2816. E-mail: [email protected].
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