Acute Headache in Emergencies

Summarized by: Vineeth Bhogadi, M.D.

Reviewed by: Elton Law, M.D.

Original publication details

Authors: Melike Guryildirim, Marinos Kontzialis, Merve Ozen, Mehmet Kocak

DOI: https://doi.org/10.1148/rg.2019190017

Reference: Guryildirim, M., Kontzialis, M., Ozen, M., & Kocak, M. (2019). Acute headache in the emergency setting. RadioGraphics, 39(6), 1739–1759.

Choice of modality

In general, initial neuroimaging should start with a noncontrast CT head 

For suspected subarachnoid aneurysmal hemorrhage (SAH), it can be confirmed on noncontrast CT but if CT is negative, a lumbar puncture is the preferred next step for the diagnosis of SAH. CT angiography (CTA) can be done to identify aneurysms.

For suspected dural venous sinus thrombosis, CT or MR venography can be done.

For suspected vascular occlusion or dissection, CT or MR angiography can be done.

For patients with cancer, suspected encephalitis, or papilledema, MRI with contrast can be done for further evaluation.

Nontraumatic hemorrhage

Often presents with a thunderclap headache and is concerning for a ruptured aneurysm. A common mimicker of a ruptured aneurysm is reversible cerebral vasoconstriction syndrome (RCVS), which causes segmental arterial vasoconstriction.

Cervical artery dissection

Headache can be the initial manifestation in patients with carotid or vertebral artery dissection. CT and MR angiography are similar in accuracy for this.

Intracranial infections

Headache is the most common manifestation. Nonenhanced CT may show sequelae such as collections or edema. Contrast-enhanced MRI is more sensitive and may show findings such as leptomeningeal enhancement.

Idiopathic intracranial hypertension (IIH)

May present with papilloedema, in which case neuroimaging is done to exclude a mass, hydrocephalus, and meningeal enhancement. If there is no papilloedema, neuroimaging is suggestive of IIH if there are 3 or more of the following: empty sella, flattening of the posterior globe, distension of the subarachnoid space +/- optic nerve vertical tortuosity, and transverse sinus stenosis.

Spontaneous intracranial hypotension

Presents with a postural headache. Noncontrast CT can be done to examine for a sagging brainstem and subdural collections. MR with contrast can be done to assess for pachymeningeal enhancement. A mamillopontine distance < 5.5 mm and pontomesencephalic angle of < 50° may occur.

Pituitary apoplexy

Presents with severe headache followed by panhypopituitarism. May be seen on CT or MR as hemorrhage in the sella.

Carbon monoxide poisoning

Presents with headaches in multiple patients from the same enclosed space. On MR or CT, ischemia can be seen in the deep gray matter, most commonly the bilateral globus pallidi.

Citation


Guryildirim, M., Kontzialis, M., Ozen, M., & Kocak, M. (2019). Acute headache in the emergency setting. RadioGraphics, 39(6), 1739–1759. https://doi.org/10.1148/rg.2019190017