Recte faciendo, neminem timeas: in ruling out the worst cause of non-traumatic headache
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LETTER TO THE EDITOR
Recte faciendo, neminem time as: in ruling out the worst cause of non‑traumatic headache Irene Paoli1 · Margherita De Nardo1 · Daniele Orso2,3 Received: 22 March 2020 / Accepted: 6 April 2020 © Belgian Neurological Society 2020
Keywords Headache · Emergency department · Guidelines · ICHD criteria Emergency medicine is a transversal discipline that often deals with non-specific presentations of a wide range of potential diseases [1] often consisting in making clinical decisions with a limited amount of data availability. The goal of the ED physician is to rule out the most serious cause of a clinical presentation. First rule: exclude immediate risk to life. In addition to reaching the diagnosis, simultaneously the emergency physician must also manage the therapy, the patient, and his family. We carefully read the study by Granato and his colleagues, “Adherence to the guidelines for the treatment of non-traumatic headache in the emergency department” [2]. The study is retrospective and, as such, being able to establish the appropriateness of diagnosis and therapy is difficult. The results observed by the authors, although conducted on a small sample and the data reflect the activity of a mediumsized emergency department of a third-level university hospital center (and this limits its generalizability), are interesting in several aspects. Adherence to the guidelines for the use of non-opioid analgesics is very high. On the other hand, the authors point out that the use of the ICHD criteria is infrequent. As far as we know, there is only one study that assessed the feasibility and performance of the ICHD criteria in the emergency department [3]. This study showed high performance. However, further clinical studies are needed to evaluate the * Daniele Orso [email protected] 1
feasibility and performance of the ICHD criteria in the emergency department. The American College of Emergency Physicians’ clinical policy supports the primary use of the Ottawa subarachnoid hemorrhage rule to rule out a headache caused by subarachnoid hemorrhage [4]. Focusing on subarachnoid hemorrhage is due to the need to rule out diseases that cause a life risk. The European Society for Emergency Medicine has not published a guideline on the topic. The Royal College of Emergency Medicine has not released its clinical guidelines or policies but refers to the National Institute for Health and Care Excellence guidance (NICE, dates 2012) [5]. The NICE guidance does not claim the use of particular scales, scores, or assessment tools for headaches in the context of primary care (they are not specifically addressed to emergency physicians). Unfortunately, this lack of guidelines makes it difficult to standardize the management of patients with non-traumatic headaches in the emergency room. Finally, we point out that the presence of a headache reference center is unfortunately not a widespread reality, and often, the small spoke centers do not have the opportunity to resort to this virtuous path. In conclusion, we believe th
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