Headache in neurological emergency
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Headache in neurological emergency Marco Longoni 1 & Elio Clemente Agostoni 2
# Fondazione Società Italiana di Neurologia 2020
Abstract Headache represents the second neurological cause of emergency room admittance. The differentiation of the small number of patients with life-threatening headaches from the overwhelming majority with benign primary headaches is an important problem in the emergency department since the misdiagnosis of a secondary headache can have serious consequences, including permanent neurologic deficits and death. The presence of one or more high-risk features (red flags) in patient clinical history or neurological examination warrants an urgent diagnostic workup including blood tests, neuroradiological studies, and lumbar puncture. Keywords Acute headache . Neurological emergency . Secondary headache . Emergency room . Red flags
Headache is a leading cause of emergency room (ER) admittance. It represents the second cause of neurological consultations in the ER, beaten only by acute cerebrovascular diseases and followed by vertigo, head trauma, acute impairment of consciousness, and epilepsy [1]. It is estimated that almost 2–4% of neurological evaluation in the emergency setting are due to headache [2]. Among them, the majority (98%) are primary headache and only a minority (< 2%) are secondary to an acute pathology affecting the central nervous system [3–5]. While treatment for benign headaches is largely supportive in nature, with a focus on prevention upon discharge, secondary headaches are, by and large, emergent in nature and may be life-threatening if not diagnosed expeditiously. Optimal diagnostic strategies to effectively identify the serious ER headaches that require emergent treatment to prevent permanent neurological sequelae are a matter of evidence-based risk stratification based on historical data, physical examination findings, social and family history, and demographic data [6]. Dangerous secondary headaches can be broadly categorized in terms of general pathophysiology into vascular, infectious, CSF related, and other than neurological (see Table 1).
* Marco Longoni [email protected]
To better evaluate the opportunity of a neuroradiological and biochemical diagnostic workup, it is very important to look for the presence of the so-called red flags in patient history and clinical examination. Indeed, a normal neurologic exam by itself reduces the risk for malignant pathology by half, from 1 in 20 to 1 in 40 (2.4%) [6, 7]. Moreover, if a history consistent with a primary headache such as migraine is added, the risk becomes acceptably manageable at 1 in 250 (0.4%) without the need for further testing [6]. In 2003, the mnemonic SNOOP [8] was proposed as a red flag detection tool for secondary headaches (see Table 2). Other items were also included as red flags from international guidelines leading to the proposal of the new SNNOOP10 [9]. In this review, we would like to approach the question firstly pointing the attention on red flags linked to headach
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