title: Emergency department evaluation of sudden, severe headache.
abstract: OBJECTIVE
  To assess the clinical management of adults presenting with sudden, severe headache.
  
  
  METHODS
  We retrospectively reviewed the medical records of consecutive adults presenting with sudden, severe headache to the emergency department (ED) or medical admissions unit at one teaching hospital.
  
  
  RESULTS
  Of 12 025 consecutive attendances over 3 months, 91 adults (0.8%, 95% CI 0.6-0.9%) presented with sudden severe headache. Documentation of time to peak headache intensity and headache duration was complete in only 33% of cases. Brain computed tomography was performed in each of the 29 patients (33%) in whom it appeared indicated for the investigation of headaches peaking within 5 min and lasting more than 1 h, as well as 11 patients (13%) who did not meet these criteria. Lumbar puncture was attempted in every patient for whom it appeared indicated (although it was unsuccessful and abandoned on three of 24 patients), as well as one patient in whom it appeared not to be indicated. When subarachnoid haemorrhage was suspected, 81% of patients had spectrophotometry. Of the patients, 52 (60%) were given a specific diagnosis, 17 (33%) of whom were given a diagnosis despite an apparently insufficient history. A further 12 (14%) could have been diagnosed if the International Headache Society classification had been applied to the documented history. Neurological advice was sought for only 20 patients (23%).
  
  
  CONCLUSIONS
  Patients with sudden, severe headache might benefit if EDs used simple protocols, emphasizing the crucial elements of history and examination, appropriate investigation and targeted consultation with neurologists.
authors.affiliation: Department of Clinical Neurosciences, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XU, Scotland. davebreen@excite.co.uk
authors.forename: D P
authors.initials: DP
authors.lastname: Breen
authors.forename: C W
authors.initials: CW
authors.lastname: Duncan
authors.forename: A E
authors.initials: AE
authors.lastname: Pope
authors.forename: A J
authors.initials: AJ
authors.lastname: Gray
authors.forename: R
authors.initials: R
authors.lastname: Al-Shahi Salman
mesh_terms: D000328:Adult; D000465:Algorithms; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D020773:Headache Disorders / Q000175:diagnosis / Q000209:etiology*; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D012017:Referral and Consultation / Q000592:standards; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis*