What is the appropriate workup for a patient presenting with headache and numbness in the Emergency Department (ED)?

From the Guidelines

A patient presenting with headache and numbness requires immediate evaluation for potential life-threatening conditions, such as subarachnoid hemorrhage, and should undergo a noncontrast head CT scan as the first step in diagnosis, as recommended by the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1.

Initial Evaluation

The initial evaluation should include a detailed history focusing on headache characteristics (onset, duration, location, quality, severity, triggers, and associated symptoms), followed by a thorough neurological examination.

• Basic laboratory tests including complete blood count, metabolic panel, ESR, and CRP should be ordered to rule out systemic causes.
• The Ottawa SAH Rule can be used to identify patients who require additional investigation for subarachnoid hemorrhage, including those with age ≥40 years, neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion on examination 1.

Neuroimaging

Neuroimaging is essential in the evaluation of headache and numbness, with noncontrast head CT being the preferred initial imaging modality for suspected subarachnoid hemorrhage.

• Noncontrast head CT scan is the cornerstone of diagnosis of subarachnoid hemorrhage, with high sensitivity in the first 3 days after symptom onset 1.
• MRI brain with and without contrast may be preferred over CT scan in certain cases, as it better visualizes posterior fossa lesions, vascular abnormalities, and demyelinating diseases.
• Additional studies may include lumbar puncture if infection or subarachnoid hemorrhage is suspected, EEG if seizures are a concern, and vascular imaging (MRA/CTA) if vascular pathology is suspected.

Management

Depending on findings, referral to neurology is appropriate, particularly if symptoms persist or worsen.

• Symptomatic treatment may include acetaminophen 650mg every 6 hours or ibuprofen 400-600mg every 6-8 hours for pain while awaiting diagnosis.
• The management of subarachnoid hemorrhage requires a multidisciplinary approach, including neurosurgery, neurology, and critical care, as outlined in the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1.

From the Research

Headache Evaluation and Workup

• A thorough history and physical examination, along with a comprehensive differential diagnosis, are essential in evaluating a headache patient 2.
• The evaluation and workup of headaches include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated 2.
• Careful attention to the patient's history and physical examination will guide the diagnostic work-up and management 2.

Red Flags and Secondary Headaches

• Headache "red flags" can suggest life-threatening secondary etiologies, such as abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes 3, 4.
• When secondary causes are suspected, appropriate neuroimaging can further differentiate the underlying cause 2.
• The appropriate imaging is dependent on the most likely secondary etiology, which is deduced from history and physical examination 2.

Primary Headaches

• Primary headaches are more likely when no red flags are present 2.
• Primary headaches can be differentiated by frequency, location, duration, triggers, and presence of aura 2.
• Tension-type headache is the most common primary headache disorder, while migraine is more debilitating and likely to present in the primary care setting 5, 3, 4.

Diagnostic Approach

• A detailed history and physical examination can distinguish between key features of a benign primary headache and concerning symptoms that warrant further evaluation for a secondary headache 4.
• The SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches 4.
• Noncontrast computed tomography of the head is recommended for emergent evaluations to exclude acute intracranial hemorrhage or mass effect 4.
• Magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features in less urgent cases 4.

Management

• Pharmacological parenteral treatment remains the principal approach for acute headache management in the emergency department 6.
• NSAIDs, neuroleptic antinauseants, triptans, and corticosteroids are commonly used, tailored to the specific headache type 6.
• Opioids should be avoided due to their scarce effectiveness in the acute phase 6.
• Referral of the patient to a Headache Center should be an integral part of the emergency department approach to headache patients 6.