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4 - Approach to Investigations

Published online by Cambridge University Press:  09 October 2017

By
Meir H. Scheinfeld  and
Benjamin W. Friedman
Edited by
Serena L. Orr ,
Benjamin W. Friedman  and
David W. Dodick
Serena L. Orr
Affiliation:
Children’s Hospital of Eastern Ontario, Ottawa
Benjamin W. Friedman
Affiliation:
Albert Einstein College of Medicine, New York
David W. Dodick
Affiliation:
Mayo Clinic, Phoenix, AZ
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Summary

Abstract

A variety of testing modalities are available in the emergency department (ED) to enable diagnosis of headache. For an emergency care provider, the goal is to order those tests that will facilitate diagnosis in a timely manner, without burdening the patient and healthcare system with unnecessary tests, particularly those tests that are time-consuming, uncomfortable, or expensive. Available diagnostic tests include analyses of blood, urine, and cerebrospinal fluid (CSF), as well as a variety of neuroimaging modalities. In this chapter, we discuss the utility, indication, and best practice with regard to the many tests commonly available in an ED.

Type
Chapter
Information
Emergency Headache
Diagnosis and Management
 , pp. 26 - 42
Publisher: Cambridge University Press
Print publication year: 2017

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References

1.Parikh, M, Miller, NR, Lee, AG, et al. Prevalence of a normal C-reactive protein with an elevated erythrocyte sedimentation rate in biopsy-proven giant cell arteritis. Ophthalmology. 2006;113(10):1842–5.CrossRefGoogle ScholarPubMed
2.Kermani, TA, Schmidt, J, Crowson, CS, et al. Utility of erythrocyte sedimentation rate and C-reactive protein for the diagnosis of giant cell arteritis. Semin Arthritis Rheum. 2012;41(6):866–71.CrossRefGoogle Scholar
3.Murchison, AP, Gilbert, ME, Bilyk, JR, et al. Validity of the American College of Rheumatology criteria for the diagnosis of giant cell arteritis. Am J Ophthalmol. 2012;154(4):722–9.CrossRefGoogle Scholar
4.Dentali, F, Squizzato, A, Marchesi, C, et al. D-dimer testing in the diagnosis of cerebral vein thrombosis: a systematic review and a meta-analysis of the literature. J Thromb Haemost. 2012;10(4):582–9.CrossRefGoogle Scholar
5.Pachner, AR, Steiner, I. Lyme neuroborreliosis: infection, immunity, and inflammation. Lancet Neurol. 2007;6(6):544–52.CrossRefGoogle Scholar
6.Makadzange, AT, McHugh, G. New approaches to the diagnosis and treatment of cryptococcal meningitis. Semin Neurol. 2014;34(1):47–60.Google ScholarPubMed
7.Bahr, NC, Boulware, DR. Methods of rapid diagnosis for the etiology of meningitis in adults. Biomark Med. 2014;8(9):1085–103.CrossRefGoogle ScholarPubMed
8.Chu, K, Hann, A, Greenslade, J, Williams, J, Brown, A. Spectrophotometry or visual inspection to most reliably detect xanthochromia in subarachnoid hemorrhage: systematic review. Ann Emerg Med. 2014;64(3):256–64.CrossRefGoogle ScholarPubMed
9.Edlow, JA. Diagnosis of subarachnoid hemorrhage. Neurocrit Care. 2005;2(2):99–109.CrossRefGoogle ScholarPubMed
10.Perry, JJ, Alyahya, B, Sivilotti, ML, et al. Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study. BMJ. 2015;350:h568.CrossRefGoogle ScholarPubMed
11.Edlow, JA, Bruner, KS, Horowitz, GL. Xanthochromia. Arch Pathol Lab Med. 2002;126(4):413–15.Google ScholarPubMed
12.Heasley, DC, Mohamed, MA, Yousem, DM. Clearing of red blood cells in lumbar puncture does not rule out ruptured aneurysm in patients with suspected subarachnoid hemorrhage but negative head CT findings. AJNR Am J Neuroradiol. 2005;26(4):820–4.Google Scholar
13.Raja, AS, Andruchow, J, Zane, R, Khorasani, R, Schuur, JD. Use of neuroimaging in US emergency departments. Arch Intern Med. 2011;171(3):260–2.CrossRefGoogle ScholarPubMed
14.Edlow, JA, Panagos, PD, Godwin, SA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407–36.CrossRefGoogle ScholarPubMed
15.Vermeulen, MJ, Schull, MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke. 2007;38(4):1216–21.CrossRefGoogle ScholarPubMed
16.Gilbert, JW, Johnson, KM, Larkin, GL, Moore, CL. Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology. Emerg Med J. 2012;29(7):576–81.CrossRefGoogle ScholarPubMed
17.Douglas, AC, Wippold, FJ 2nd, Broderick, DF, et al. ACR appropriateness criteria headache. J Am Coll Radiol. 2014;11(7):657–67.CrossRefGoogle ScholarPubMed
18.Silberstein, SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754–62.CrossRefGoogle ScholarPubMed
19.Frishberg, B, Rosenberg, JH, Matchar, DB, Pietrzak, MP, Rozen, TD. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. 2000 Available from the American Academy of Neurology. Available at: http://tools.aan.com/professionals/practice/pdfs/gl0088.pdf.Google Scholar
20.Pearce, MS, Salotti, JA, Little, MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012;380(9840):499–505.CrossRefGoogle ScholarPubMed
21.Zorbalar, N, Yesilaras, M, Aksay, E. Carbon monoxide poisoning in patients presenting to the emergency department with a headache in winter months. Emerg Med J. 2014;31(e1):e66–70.CrossRefGoogle ScholarPubMed
22.Brodsky, MC, Vaphiades, M. Magnetic resonance imaging in pseudotumor cerebri. Ophthalmology. 1998;105(9):1686–93.CrossRefGoogle ScholarPubMed
23.Bradley, WG Jr. MR appearance of hemorrhage in the brain. Radiology. 1993;189(1):15–26.CrossRefGoogle Scholar
24.De Benedittis, G, Lorenzetti, A, Sina, C, Bernasconi, V. Magnetic resonance imaging in migraine and tension-type headache. Headache. 1995;35(5):264–8.CrossRefGoogle ScholarPubMed
25.Randeva, HS, Schoebel, J, Byrne, J, et al. Classical pituitary apoplexy: clinical features, management and outcome. Clin Endocrinol (Oxf). 1999;51(2):181–8.CrossRefGoogle ScholarPubMed
26.Boellis, A, di Napoli, A, Romano, A, Bozzao, A. Pituitary apoplexy: an update on clinical and imaging features. Insights Imaging. 2014;5(6):753–62.CrossRefGoogle ScholarPubMed
27.Tentschert, S, Wimmer, R, Greisenegger, S, Lang, W, Lalouschek, W. Headache at stroke onset in 2196 patients with ischemic stroke or transient ischemic attack. Stroke. 2005;36(2):e1–3.CrossRefGoogle ScholarPubMed
28.Schwedt, TJ, Dodick, DW. Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache. Headache. 2006;46(3):520–2.CrossRefGoogle ScholarPubMed
29.Karassa, FB, Matsagas, MI, Schmidt, WA, Ioannidis, JP. Meta-analysis: test performance of ultrasonography for giant-cell arteritis. Ann Intern Med. 2005;142(5):359–69.CrossRefGoogle ScholarPubMed
30.Bley, TA, Uhl, M, Carew, J, et al. Diagnostic value of high-resolution MR imaging in giant cell arteritis. AJNR Am J Neuroradiol. 2007;28(9):1722–7.CrossRefGoogle ScholarPubMed
31.Perry, JJ, Stiell, IG, Sivilotti, ML, et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ. 2010;341:c5204.CrossRefGoogle ScholarPubMed
32.Perry, JJ, Stiell, IG, Sivilotti, ML, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA. 2013;310(12):1248–55.CrossRefGoogle ScholarPubMed
33.Grimaldi, D, Nonino, F, Cevoli, S, et al. Risk stratification of non-traumatic headache in the emergency department. J Neurol. 2009;256(1):51–7.CrossRefGoogle ScholarPubMed
34.De Luca, GC, Bartleson, JD. When and how to investigate the patient with headache. Semin Neurol. 2010;30(2):131–44.CrossRefGoogle ScholarPubMed
35.Sempere, AP, Porta-Etessam, J, Medrano, V, et al. Neuroimaging in the evaluation of patients with non-acute headache. Cephalalgia. 2005;25(1):30–5.CrossRefGoogle ScholarPubMed
36.Lewis, DW, Ashwal, S, Dahl, G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches – report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002;59(4):490–8.CrossRefGoogle ScholarPubMed
37.Pascual, J, González-Mandly, A, Martín, R, Oterino, A. Headaches precipitated by cough, prolonged exercise or sexual activity: a prospective etiological and clinical study. J Headache Pain. 2008;9(5):259–66.CrossRefGoogle ScholarPubMed
38.Landtblom, AM, Fridriksson, S, Boivie, J, et al. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia. 2002;22(5):354–60.CrossRefGoogle ScholarPubMed
39.Cuvinciuc, V, Viguier, A, Calviere, L, et al. Isolated acute nontraumatic cortical subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2010;31(8):1355–62.CrossRefGoogle ScholarPubMed
40.Nishijima, DK, Offerman, SR, Ballard, DW, et al. Risk of traumatic intracranial hemorrhage in patients with head injury and preinjury warfarin or clopidogrel use. Acad Emerg Med. 2013;20(2):140–5.CrossRefGoogle ScholarPubMed
41.Hart, RG, Diener, HC, Yang, S, et al. Intracranial hemorrhage in atrial fibrillation patients during anticoagulation with warfarin or dabigatran: the RE-LY trial. Stroke. 2012;43(6):1511–17.CrossRefGoogle ScholarPubMed
42.Gorelick, PB, Weisman, SM. Risk of hemorrhagic stroke with aspirin use: an update. Stroke. 2005;36(8):1801–7.CrossRefGoogle ScholarPubMed
43.Garbe, E, Kreisel, SH, Behr, S. Risk of subarachnoid hemorrhage and early case fatality associated with outpatient antithrombotic drug use. Stroke. 2013;44(9):2422–6.CrossRefGoogle ScholarPubMed
44.Bederson, JB, Connolly, ES Jr, Batjer, HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40(3):994–1025.CrossRefGoogle Scholar
45.Pierot, L, Portefaix, C, Rodriguez-Régent, C, et al. Role of MRA in the detection of intracranial aneurysm in the acute phase of subarachnoid hemorrhage. J Neuroradiol. 2013;40(3):204–10.CrossRefGoogle ScholarPubMed
46.Romijn, M, Gratama van Andel, HA, van Walderveen, MA, et al. Diagnostic accuracy of CT angiography with matched mask bone elimination for detection of intracranial aneurysms: comparison with digital subtraction angiography and 3D rotational angiography. AJNR Am J Neuroradiol. 2008;29(1):134–9.CrossRefGoogle ScholarPubMed
47.Luo, Z, Wang, D, Sun, X, et al. Comparison of the accuracy of subtraction CT angiography performed on 320-detector row volume CT with conventional CT angiography for diagnosis of intracranial aneurysms. Eur J Radiol. 2012;81(1):118–22.CrossRefGoogle ScholarPubMed
48.Delgado Almandoz, JE, Jagadeesan, BD, Refai, D, et al. Diagnostic yield of computed tomography angiography and magnetic resonance angiography in patients with catheter angiography-negative subarachnoid hemorrhage. J Neurosurg. 2012;117(2):309–15.CrossRefGoogle ScholarPubMed
49.van Gijn, J, van Dongen, KJ. The time course of aneurysmal haemorrhage on computed tomograms. Neuroradiology. 1982;23(3):153–6.CrossRefGoogle ScholarPubMed
50.Backes, D, Rinkel, GJ, Kemperman, H, Linn, FH, Vergouwen, MD. Time-dependent test characteristics of head computed tomography in patients suspected of nontraumatic subarachnoid hemorrhage. Stroke. 2012;43(8):2115–19.CrossRefGoogle Scholar
51.Stewart, H, Reuben, A, McDonald, J. LP or not LP, that is the question: gold standard or unnecessary procedure in subarachnoid haemorrhage? Emerg Med J. 2014;31(9):720–3.CrossRefGoogle ScholarPubMed
52.Perry, JJ, Stiell, IG, Sivilotti, ML, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;34 3:d4277.CrossRefGoogle Scholar
53.Edlow, JA, Fisher, J. Diagnosis of subarachnoid hemorrhage: time to change the guidelines? Stroke. 2012;43(8):2031–2.CrossRefGoogle Scholar
54.Mark, DG, Hung, YY, Offerman, SR, et al. Nontraumatic subarachnoid hemorrhage in the setting of negative cranial computed tomography results: external validation of a clinical and imaging prediction rule. Ann Emerg Med. 2013;62(1):1–10.CrossRefGoogle ScholarPubMed
55.Fine, B, Singh, N, Aviv, R, Macdonald, RL. Decisions: does a patient with a thunderclap headache need a lumbar puncture? CMAJ. 2012;184(5):555–6.CrossRefGoogle Scholar
56.Wiesmann, M, Mayer, TE, Yousry, I, et al. Detection of hyperacute subarachnoid hemorrhage of the brain by using magnetic resonance imaging. J Neurosurg. 2002;96(4):684–9.CrossRefGoogle ScholarPubMed
57.Yuan, MK, Lai, PH, Chen, JY, et al. Detection of subarachnoid hemorrhage at acute and subacute/chronic stages: comparison of four magnetic resonance imaging pulse sequences and computed tomography. J Chin Med Assoc. 2005;68(3):131–7.CrossRefGoogle ScholarPubMed
58.Hodel, J, Aboukais, R, Dutouquet, B, et al. Double inversion recovery MR sequence for the detection of subacute subarachnoid hemorrhage. AJNR Am J Neuroradiol. 2014;36(2):251–8.Google ScholarPubMed
59.Verma, RK, Kottke, R, Andereggen, L, et al. Detecting subarachnoid hemorrhage: comparison of combined FLAIR/SWI versus CT. Eur J Radiol. 2013;82(9):1539–45.CrossRefGoogle ScholarPubMed
60.Woodcock, RJ Jr, Short, J, Do, HM, Jensen, ME, Kallmes, DF. Imaging of acute subarachnoid hemorrhage with a fluid-attenuated inversion recovery sequence in an animal model: comparison with non-contrast-enhanced CT. AJNR Am J Neuroradiol. 2001;22(9):1698–703.Google Scholar
61.Schievink, WI, Maya, MM, Louy, C, Moser, FG, Tourje, J. Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension. AJNR Am J Neuroradiol. 2008;29(5):853–6.CrossRefGoogle ScholarPubMed
62.Ramchandren, S, Cross, BJ, Liebeskind, DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. AJNR Am J Neuroradiol. 2007;28(6):1085–7.CrossRefGoogle ScholarPubMed
63.McCollough, CH, Schueler, BA, Atwell, TD, et al. Radiation exposure and pregnancy: when should we be concerned? Radiographics. 2007;27(4):909–17.CrossRefGoogle ScholarPubMed
64.Perry, JJ, Spacek, A, Forbes, M, et al. Is the combination of negative computed tomography result and negative lumbar puncture result sufficient to rule out subarachnoid hemorrhage? Ann Emerg Med. 2008;51(6):707–13.CrossRefGoogle ScholarPubMed
65.Horstman, P, Linn, FH, Voorbij, HA, Rinkel, GJ. Chance of aneurysm in patients suspected of SAH who have a “negative” CT scan but a “positive” lumbar puncture. J Neurol. 2012;259(4):649–52.CrossRefGoogle ScholarPubMed
66.McCormack, RF, Hutson, A. 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? Acad Emerg Med. 2010;17(4):444–51.CrossRefGoogle ScholarPubMed
67.Swadron, SP. Pitfalls in the management of headache in the emergency department. Emerg Med Clin North Am. 2010;28(1):127–47.CrossRefGoogle ScholarPubMed
68.Ward, MJ, Bonomo, JB, Adeoye, O, Raja, AS, Pines, JM. Cost-effectiveness of diagnostic strategies for evaluation of suspected subarachnoid hemorrhage in the emergency department. Acad Emerg Med. 2012;19(10):1134–44.CrossRefGoogle ScholarPubMed
69.Edlow, JA. What are the unintended consequences of changing the diagnostic paradigm for subarachnoid hemorrhage after brain computed tomography to computed tomographic angiography in place of lumbar puncture? Acad Emerg Med. 2010;17(9):991–5.CrossRefGoogle ScholarPubMed
70.Kong, DS, Hong, SC, Jung, YJ, Kim, JS. Improvement of chronic headache after treatment of unruptured intracranial aneurysms. Headache. 2007;47(5):693–7.CrossRefGoogle ScholarPubMed
71.Rinkel, GJ, Djibuti, M, Algra, A, van Gijn, J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke. 1998;29(1):251–6.CrossRefGoogle ScholarPubMed
72.Devenney, E, Neale, H, Forbes, R, Raeburn, B. A systematic review of causes of sudden and severe headache (thunderclap headache): should lists be evidence based? J Head Pain. 2014;15:49.CrossRefGoogle ScholarPubMed
73.Ducros, A, Hajj-Ali, RA, Singhal, AB, Wang, SJ. Reversible cerebral vasoconstriction syndrome. JAMA Neurology. 2014;71:368.CrossRefGoogle ScholarPubMed
74.Lucas, S, Hoffman, JM, Bell, KR, Dikmen, S. A prospective study of prevalence and characterization of headache following mild traumatic brain injury. Cephalalgia. 2014;34:93–102.CrossRefGoogle ScholarPubMed
75.Ryan, LM, Warden, DL. Post concussion syndrome. Int Rev Psychiatry. 2003;15(4):310–16.CrossRefGoogle ScholarPubMed
76.https://acsearch.acr.org/docs/69481/Narrative.
77.Jagoda, AS, Bazarian, JJ, Bruns, JJ Jr, et al. Clinical policy: neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52(6):714–48.CrossRefGoogle ScholarPubMed
78.Neff, MJ. Evidence based guidelines for neuroimaging in patients with nonacute headache. Am Fam Physician. 2005;71(6):1219–22.Google Scholar
79.Rinkel, GJ, Djibuti, M, Algra, A, van Gijn, J. Prevalence and risk of rupture of intracranial aneurysms: a systematic review. Stroke. 1998;29(1):251–6.CrossRefGoogle ScholarPubMed
80.Loder, E, Weizenbaum, E, Frishberg, B, Silberstein, S; American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651–9.CrossRefGoogle ScholarPubMed
81.Howard, L, Wessely, S, Leese, M, et al. Are investigations anxiolytic or anxiogenic? A randomised controlled trial of neuroimaging to provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry. 2005;76(11):1558–64.CrossRefGoogle ScholarPubMed
82.Evans, RW. Medico-legal headaches: trials and tribulations. In Advanced Therapy of Headache, 2nd ed. Edited by Purdy, RA, Rapoport, A, Sheftell, F, Tepper, S. Hamilton, ON: BC Decker; 2005, 229–38.Google Scholar
83.Wang, HZ, Simonson, TM, Greco, WR, Yuh, WT. Brain MR imaging in the evaluation of chronic headache in patients without other neurologic symptoms. Acad Radiol. 2001;8(5):405–8.CrossRefGoogle ScholarPubMed
84.Weingarten, S, Kleinman, M, Elperin, L, Larson, EB. The effectiveness of cerebral imaging in the diagnosis of chronic headache. Arch Intern Med. 1992;152(12):2457–62.CrossRefGoogle Scholar
85.Sudlow, C. US guidelines on neuroimaging in patients with non-acute headache: a commentary. J Neurol Neurosurg Psychiatry. 2002;72(Suppl. 2):ii16–18.Google ScholarPubMed
86.Waldman, CW, Waldman, SD, Waldman, RA. Pain of ocular and periocular origin. Med Clin North Am. 2013;97(2):293–307.CrossRefGoogle ScholarPubMed
87.Fink, KR, Fink, JR. Imaging of brain metastases. Surg Neurol Int. 2013;4(Suppl. 4):S209–19.CrossRefGoogle ScholarPubMed
88.Expert Panel on Radiation Oncology-Brain Metastases, Lo, SS, Gore, EM, et al. ACR Appropriateness Criteria® pre-irradiation evaluation and management of brain metastases. J Palliat Med. 2014;17(8):880–6.CrossRefGoogle ScholarPubMed
89.Cornelius, RS, Martin, J, Wippold, FJ 2nd, et al. ACR appropriateness criteria sinonasal disease. J Am Coll Radiol. 2013;10(4):241–6.CrossRefGoogle ScholarPubMed
90.Anzai, Y. Evaluation of sinusitis: evidence-based neuroimaging. In Evidence-Based Neuroimaging Diagnosis and Treatment. Edited by Medina, LS, Sanelli, PC, Jarvik, JG. New York: Springer; 2013, 581–97.CrossRefGoogle Scholar
91.Chow, AW, Benninger, MS, Brook, I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–112.CrossRefGoogle ScholarPubMed

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