St Emlyn´s - January 7, 2016 - By Chris Gray
"Around 2-5% of patients presenting to the Emergency Department will be there because of a headache. Most of these are benign, but it’s not uncommon to be faced with a patient with the worst headache of their life. Until now, it has been recommended that all patients with a clinical suspicion of sub-arachnoid haemorrhage and a negative CT head be referred for a lumbar puncture at 12 hours after the onset of headache. Is it time for a change? Can we send some of these patients home? Can we avoid referring them for what can be an unpleasant procedure?
In summary.
In patients presenting with lone headache, with clinical suspicion of subarachnoid haemorrhage but no adverse features, a CT head is sufficient to rule this out, if performed within 6 hours of onset on a thin-slice, 3rd generation CT and reported by an experienced radiologist.
For patients who do not meet the above criteria, or those presenting after 6 hours, an urgent CT head should be requested, and if negative, current evidence suggests these patients could also be discharged.
If there is a high clinical concern for subarachnoid haemorrhage despite negative imaging (for example in patients with previous SAH), the patient should be referred for further investigation.
Patients who are discharged should be given advice to return if they develop adverse features such as neurology or decreased conscious level, or are concerned about new or evolving symptoms.
Of course, if they have a positive scan, urgent neurosurgical opinion should be sought and local guidelines followed regarding management."