An international study of emergency physicians' practice for acute headache management and the need for a clinical decision rule

CJEM. 2009 Nov;11(6):516-22. doi: 10.1017/s1481803500011775.


Objective: Patients with acute headache often undergo computed tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study examined current practice, the perceived need for a clinical decision rule for acute headache and the required sensitivity for such a rule.

Methods: We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3-5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neurologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country.

Results: The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency department (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investigated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%-99%). Approximately 1 in 5 physicians suggested that 100% sensitivity was required.

Conclusion: Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED.

MeSH terms

  • Acute Disease
  • Adult
  • Aged
  • Australia
  • Canada
  • Decision Making*
  • Diagnosis, Differential
  • Emergency Medicine*
  • Female
  • Headache / diagnosis*
  • Humans
  • Male
  • Middle Aged
  • Practice Patterns, Physicians' / statistics & numerical data*
  • Spinal Puncture
  • Subarachnoid Hemorrhage / diagnosis
  • Surveys and Questionnaires
  • Tomography, X-Ray Computed
  • United Kingdom
  • United States