What is the emergency department work-up for a patient presenting with a headache described as a parietal spasm?

From the Guidelines

The emergency department workup for a headache described as a parietal spasm should include a non-contrast CT scan of the head to exclude hemorrhage, mass, or structural abnormalities, as recommended by the most recent guidelines 1. The initial assessment should also include a thorough neurological examination, vital signs assessment, and focused history to rule out dangerous causes.

• Key elements of the history include:
  • Sudden onset of severe headache
  • Fever
  • Neck stiffness
  • Altered mental status
• If the patient has any of these symptoms, a lumbar puncture may be necessary to rule out meningitis or subarachnoid hemorrhage, as suggested by previous guidelines 1. However, according to the most recent guidelines 1, if a third-generation or higher CT scan is performed within six hours of onset of headache and read as normal by a neuroradiologist, a lumbar puncture is not required. Treatment typically begins with NSAIDs such as ibuprofen 400-600mg orally every 6 hours or ketorolac 30mg IV/IM for more severe pain.
• For migraine-like symptoms, consider:
  • Sumatriptan 6mg subcutaneously or 50-100mg orally
  • Metoclopramide 10mg IV with diphenhydramine 25mg IV to reduce side effects Intravenous fluids should be provided if the patient is dehydrated.
• Patients should be advised to follow up with their primary care provider within 1-2 weeks, and return immediately if they experience:
  • Worsening symptoms
  • Fever
  • Vision changes
  • Neurological deficits The parietal location may suggest a tension-type headache or migraine, but careful evaluation is needed to exclude secondary causes like temporal arteritis in older patients or intracranial pathology.

From the Research

Emergency Department Workup for Headache

• 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 2.
• The SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches, and red flag signs or symptoms such as acute thunderclap headache, fever, meningeal irritation, papilledema, impaired consciousness, and concern for acute glaucoma warrant immediate evaluation 2.
• For emergent evaluations, noncontrast computed tomography of the head is recommended to exclude acute intracranial hemorrhage or mass effect, and a lumbar puncture is also needed to rule out subarachnoid hemorrhage if the scan result is normal 2, 3.

Diagnostic Approach

• A systematic framework such as the SNNOOP10 mnemonic can help detect life-threatening secondary causes of headaches 2.
• Evaluating acute headaches using a systematic framework can help detect secondary headache disorders, which are defined as headaches due to an underlying medical condition 4.
• Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder, and they should be evaluated for symptoms or signs that suggest an urgent medical problem 4.

Imaging Studies

• Computed tomography is more sensitive to acute hemorrhage than is MRI, and MRI frequently contributes information to narrow the diagnostic possibilities when the patient is stable 3.
• Magnetic resonance imaging shows excellent detail of the disk and surrounding soft tissues, whereas tomography better demonstrates bony changes, and MRI will generally show superior characterization 3.
• For less urgent cases, magnetic resonance imaging of the brain is preferred for evaluating headaches with concerning features 2.