Headache Guidelines - Indications for Imaging

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Michael F. -

Would like Mike and Jonathan's opinion on the adequacy of the CT/CTA strategy for rule out SAH without respect to effects on downstream testing (whole other can of worms). Had moderately concerning history (thunderclap HA), less than 6 hours PTA, no prior HA history. Head CT negative on dual source scanner read by my staff radiologist. Attempted to LP but unable to obtain. Don't have access to fluoro guided LP and i don't know how to do with US. Big struggle to transfer tertiary with multiple phone calls over hours. Several interesting caveats during this journey.

1. One neuroradiologist told me that a SAH with negative CT on current hardware is basically hypothetical and LP is unnecessary.

2. When patient got to tertiary care facility, their tap was traumatic and CTA was negative which their neurosurgeon thought was sufficient (no neurosurgeon at my facility).

Did I just waste mine and the patient's time because I could have gotten a CTA at my shop. Is the CT/CTA strategy robust enough I can go there on my own. Thanks

Chris B. -

Hey guys,

Great segment on headache.

Jonathan said the time to onset in the Perry BMJ paper was 5 minutes. Unfortunately, it was 60 minutes, which raises the question, "should we be getting CTs on people where the headache peaks within an hour. The definition of "thunderclap" is ill defined, though I would expect most clinicians would say within 1 or 5 minutes.

Does the Perry study criteria of peak intensity within 60 minutes muddy the waters and mean we should be ordering more CTs in this group of patients?

Appreciate your thoughts.


Pierre M. -

In the discussion of the Perry article it was stated that thunderclap headache was defined as one that reaches maximum intensity within 10 minutes. It was actually defined as a headache reaching maximal intensity within one hour.

New Kid, MD -

I wish the segment would have also addressed hypertensive encephalopathy headache and imaging.

Patrick T. -

I work in small rural ER's in southern colorado and if you tap, you have no way of testing for xanthochromia other than by gross visual.

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