Clinical Policy:
Critical Issues in the Evaluation
and Management of Patients
Presenting to the Emergency Department
with Acute Headache
September 11, 2001

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

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

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

Level C recommendations. Adult patients with headache
exhibiting signs of increased intracranial pressure including
papilledema, absent venous pulsations on funduscopic
examination, altered mental status, or focal neurologic
deficits should undergo a neuroimaging study before having
an LP.
In the absence of findings suggestive of increased intracranial
pressure, an LP can be performed without obtaining
a neuroimaging study. (Note: An LP does not assess for
all causes of a sudden severe headache.)

III. Which patients with headache require neuroimaging in the
ED?

Level B recommendations. Patients presenting to the ED
with headache and abnormal findings in a neurologic
examination (ie, focal deficit, altered mental status,
altered cognitive function) should undergo emergent*
noncontrast head CT scan.
Patients presenting with acute sudden-onset headache
should be considered for an emergent* head CT scan.
HIV-positive patients with a new type of headache
should be considered for an urgent* neuroimaging study.
Level C recommendations. Patients who are older than
50 years presenting with new type of headache without
abnormal findings in a neurologic examination should be
considered for an urgent neuroimaging study.

IV. Is there a need for emergent angiography in the patient
with a “thunderclap headache” who has negative findings in
both CT and LP?

Level C recommendations. Patients with a thunderclap headache who
have negative findings in a head CT scan, normal opening
pressure, and negative findings in CSF analysis do not need
emergent angiography and can be discharged from the ED with
follow-up arranged with their primary care provider or
neurologist