ACEP guidelines on acute nontraumatic headache diagnosis and management in the Emergency Department, Commentary on behalf of the Refractory, In-patient, Emergency Care section of the American Headache Society, reviewed and approved by the Board of Directors of the American Headache Society

Abstract

The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute non-traumatic headaches in the Emergency Department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists’ perspective, written on behalf of the Refractory, In-patient, Emergency Care section of the American Headache Society. The commentary have been reviewed and approved by Board of Directors of the American Headache Society.

Background

Patients presenting to the Emergency Department with a chief complaint of headache account for 5 million visits to Emergency Departments annually. While migraine causes approximately 1/3 of these visits (1) , life-threatening disorders can also present with headache and it is essential to exclude these possibilities. The American College of Emergency Physicians recently published guidelines on the diagnosis and management of acute non-traumatic headaches in the Emergency Department(***). The following questions were proposed and addressed:

1. In the adult ED patient presenting with acute headache, are there risk stratification strategies that reliably identify the need for emergent neuroimaging?

This section appropriately focuses on ruling out subarachnoid hemorrhage (SAH), one of the most important diagnostic consideration in patients presenting to the ED with acute headache. This section also appropriately identifies SAH patients as a subset of cases of sudden-onset severe headache. As referenced in the ACEP policy, in Landtblom et al’s prospective study of thunderclap headaches, 23 had SAH, 5 had cerebral infarction, 3 had intracerebral hemorrhage, 4 had aseptic meningitis, 1 had cerebral edema, and 1 had sinus thrombosis (2). Thus, while critically important, ruling SAH out is not sufficient to exclude other secondary headaches. It is essential to have a decision tool that will rule out other common and life-threatening causes of acute headache in addition to SAH. Specifically, this commentary suggests considering imaging when patients present with an acute headache during the peri and post-partum periods, have risk factors for immunocompromise, recent head trauma, or cardiovascular disorders.

2. In the adult ED patient treated for acute primary headache, are non-opioids preferred to opioid medications?

Unfortunately, the current practice of prescribing opioids for the management of acute migraine is widespread, with the nearly 20% of patients attending a tertiary care headache center for the treatment of migraine, a chronic condition that presents with acute exacerbations, reporting that they first received opioids in the Emergency Department (3). Prescription of opioids sets up an ill-advised precedent for patients to continue to rely on these medicines after leaving the ED. The ACEP Clinical Policy document’s recommendation to preference non-opioid to opioid medications in the adult ED patient with acute primary headaches is a greatly appreciated position that promotes patient-safe and positive treatments of acute primary headaches. Moreover, the identification of no potential harm to this recommendation is helpful and reassuring to clinicians. The recommendation is based on efficacy of the medication within the few hours in which pain is assessed post medication administration. As discussed in the ACEP Clinical Policy document and in the Orr et al American Headache Society Evidence Assessment of Parenteral Pharmacotherapies, there is also a concern for sub-acute and long-term sequelae with opioid use (4). Opioids increase the risk for migraine chronification (5) and impede the reversal of central sensitization in patients with migraine. Patients who receive opioids in the ED have higher recidivism rates (6), and lower pain threshold (7). Opioids have little to no role in the treatment of primary headaches and this is one of the most important tenets in the guidelines.

The ACEP guidelines state that, “Two Class III specialty society systematic reviews were identified.” These were American Headache Society Guidelines done in accordance with the American Academy of Neurology guideline process.

It is critical for Neurologists and headache specialists to support ED physicians not only by providing strong rationale for avoiding opioids but also alternative, non-opioid based, treatment options. These non-opioid based treatment options for patients presenting with an acute migraine exacerbation, have been highlighted in Orr et al. The AHS guidelines suggest the following medications “should be offered” for the treatment of migraine in the emergency department - sumatriptan injectable, metoclopramide, and prochlorperazine. The AHS guidelines also suggest clinicians “may offer” the following medications intravenously - acetaminophen, acetylsalicylic acid, chlorpromazine, dexketoprofen, diclofenac, droperidol, haloperidol, ketorolac, valproate (4). Other promising therapies that may warrant investigation into their efficacy in migraine management the ED setting include occipital nerve blocks, sphenopalatine ganglion blocks, along with newly emerging therapies including medications and neuromodulatory devices. Nerve blocks may deserve special attention given increasing evidence of efficacy (8) and the particularly benign safety profile of this treatment option.

In the "Future Research" section, patient care plans are discussed. We would like to highlight protocols for headache management which may help to reduce the use of opioids for the acute treatment of primary headaches in the Emergency Department setting. Zubair et al discuss implementing an algorithm for managing headaches in the ED (9). This is one example of an approach to supporting care of patients with migraine in the ED while reducing recidivism.

Along with ACEP’s strong position on opioids we would also recommend ED physicians minimize the use butalbital/acetaminophen/caffeine compounds. These butalbital-containing compounds should be avoided as recommended treatment for migraine and tension-type headache in the ED. This recommendation brings the ACEP guidelines into line with guidelines from the AHS and AAN. (10, 11)

3. In the adult ED patient presenting with acute headache, does a normal noncontrast head CT performed within 6 hours of headache onset preclude the need for further diagnostic workup for subarachnoid hemorrhage?

The level B recommendation to rule out nontraumatic SAH based on a normal non-contrast head CT performed within 6 hours of symptom onset relies in large part upon Perry et al’s data whose studies include highly trained radiologists (neurologists or general radiologists who regularly interpret head CTs) (12). For this reason, the results may not be reproducible at other institutions, and we appreciate the placement of level B on the recommendation. In addition, the policy appropriately raises concern about the variable quality of CT scans and the lack of controlling for CT scan quality across studies. We appreciate and agree with ACEP’s guideline on non-contrast CT for SAH.

4. In the adult ED patient who is still considered to be at risk for SAH after a negative non-contrast head CT, is CTA of the head as effective as LP to safely rule out SAH?

This question specifically addresses SAH, which, as mentioned previously, while important, is but one of several concerning diagnoses in patients presenting to the ED with acute headache. We appreciate the policy’s fair assessment of the data, acknowledging a paucity of data directly comparing CT/LP versus CT/CTA. In this setting, lumbar puncture is an invaluable tool for diagnosing many causes of acute headache. While minimally invasive (relative to imaging), it is a safe and powerful diagnostic tool, in the context of diagnosing a variety of conditions beyond SAH, such as meningitis and intracranial hypertension or hypotension. In addition, we would like to highlight the role of CTA in diagnosing SAH and other causes of thunderclap headache such as dissection.

Additional comment

Please note that the preferred term is now “migraine” and not “migraine headaches” as there are many symptoms of migraine besides headache (e.g. nausea, vomiting, sensory phobias, dizziness).

Conclusions

The contribution of the ACEP Clinical Policies document is a welcome addition to the body of resources available to ED physicians when addressing a severe headache in the acute setting. A clearer understanding of diagnostic tools and differential diagnosis, consideration of imaging where appropriate, and facilitation of more effective and safe treatments of acute primary headaches is essential to improving overall care and outcomes. Future research can benefit from a focus on systematic analyses of other red flags that may warn of secondary headache as more options emerge for treatment of severe primary headache.

With respect to the treatment recommendations, part 2, we strongly support the recommendation to preference non-opioid medications for the treatment of acute primary headache and highlighting the lack of efficacy of opioids as well as the short- and long- term consequences of using opioids to treat migraine exacerbations.