Workup for Head Trauma with Headache
A noncontrast head CT is indicated for this patient with head trauma and headache, as headache alone meets ACEP Level A criteria for imaging when loss of consciousness (LOC) or post-traumatic amnesia (PTA) occurred, and meets Level B criteria even without LOC/PTA if the headache is severe. 1
Clinical Assessment Framework
First, determine the presence or absence of LOC or PTA, as this dictates which imaging criteria apply:
If LOC or PTA Present (Level A Recommendation):
Order noncontrast head CT immediately if the patient has headache plus any of the following 1:
- Vomiting
- Age >60 years
- Drug or alcohol intoxication
- Short-term memory deficits
- Physical trauma evidence above the clavicle
- Post-traumatic seizure
- GCS score <15
- Focal neurologic deficit
- Coagulopathy (warfarin, heparin, NOACs, or antiplatelet agents)
Since headache is explicitly listed as an indication, this patient requires CT scanning if LOC or PTA occurred.
If NO LOC or PTA (Level B Recommendation):
Consider noncontrast head CT if any of the following are present 1:
- Focal neurologic deficit
- Vomiting
- Severe headache (key distinction here)
- Age ≥65 years
- Physical signs of basilar skull fracture
- GCS score <15
- Coagulopathy
- Dangerous mechanism (ejection from vehicle, pedestrian struck, fall >3 feet or 5 stairs)
Critical Decision Points
The severity of headache matters when there is no LOC/PTA. A simple fall hitting the head with mild headache in a young patient without other risk factors may not require imaging, whereas severe headache warrants CT even without LOC 1.
Age thresholds differ: >60 years with LOC/PTA versus ≥65 years without LOC/PTA 1.
Coagulopathy is an absolute indication regardless of mechanism severity. This includes warfarin, NOACs, heparin, and even antiplatelet therapy (aspirin, clopidogrel), though some controversy exists for antiplatelet agents alone in minimal trauma 1, 2.
Common Pitfalls
Do not skip imaging based on mechanism alone. Recent evidence shows that even very low-force mechanisms (hitting a shelf while standing) rarely cause intracranial injury 3, but the 2021 ACR guidelines still recommend applying clinical decision rules rather than dismissing based on mechanism.
Do not order MRI acutely. MRI has no role in initial head trauma evaluation—CT is the standard for detecting neurosurgical lesions like hemorrhage 1.
Do not order skull radiographs. These have been replaced by CT, which is far more sensitive for clinically significant injuries 1.
Do not use CTA, MRA, PET, or SPECT unless vascular injury is specifically suspected 1.
If CT is Negative
Discharge is appropriate for patients with normal CT and normal neurologic examination (GCS 15) 1.
Admit for observation if GCS remains <15 after negative CT, with half-hourly neuro checks until GCS 15 is achieved 1.
Routine repeat CT is not indicated after negative initial CT unless neurologic deterioration occurs. The risk of delayed intracranial hemorrhage is extremely low (0.04-0.3%) even in anticoagulated patients 1, 2.
MRI may be considered later only if persistent unexplained neurologic deficits exist after negative CT, as it detects subtle contusions and diffuse axonal injury better than CT, though this rarely changes acute management 1.
Algorithm Summary
- Assess for LOC/PTA
- Check GCS score (if <15, CT is indicated)
- Evaluate headache severity (severe = CT even without LOC/PTA)
- Screen for high-risk features: age, coagulopathy, vomiting, focal deficits, dangerous mechanism
- Order noncontrast head CT if any criteria met
- If CT negative and GCS 15: discharge with return precautions
- If CT negative but GCS <15: admit for observation
This approach balances the 100% sensitivity needed to detect neurosurgical lesions (occurring in <1% of mild head trauma) against avoiding unnecessary imaging in the 90% of patients who will have normal scans 1.