Nontraumatic headaches in the emergency department: evaluation of a clinical pathway

Headache. 2009 Sep;49(8):1174-85. doi: 10.1111/j.1526-4610.2009.01482.x. Epub 2009 Jul 8.


Objective: To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED).

Background: Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence-based operative protocol are lacking.

Methods: A before-after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6-month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED.

Results: A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: -11.3%, 95% confidence intervals [CI]: -18.7% to -3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: -5.7%, 95% CI: -10.6% to -0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: -3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 +/- 102 minutes vs 180.5 +/- 105 minutes, difference: -9.8 minutes, 95% CI: -20.3 to 5.7; P = .09). A 6-month follow-up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: -0.33%, 95% CI: -2.1% to 0.9%; P = .5).

Conclusions: Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.

MeSH terms

  • Adult
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Antiemetics / therapeutic use
  • Causality
  • Clinical Protocols*
  • Diagnosis, Differential
  • Diagnostic Errors / statistics & numerical data
  • Emergency Medical Services / methods*
  • Emergency Medical Services / statistics & numerical data*
  • Female
  • Headache / classification
  • Headache / diagnosis*
  • Headache / therapy*
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Patient Admission / statistics & numerical data
  • Predictive Value of Tests
  • Referral and Consultation / statistics & numerical data
  • Retrospective Studies
  • Software Design
  • Tomography, X-Ray Computed / statistics & numerical data


  • Anti-Inflammatory Agents, Non-Steroidal
  • Antiemetics