A 42 year old woman became aware of a mild global headache while warming up for her aerobic class. Several minutes later (before the class started), she had sudden exacerbation of her headache, followed by vomiting and photophobia. She was seen by her GP, who diagnosed migraine and gave her intramuscular morphine and prochlorperazine. She spent the next four days in bed with her worst ever headache (she had a previous history of migraine without aura, but this was much worse). On day 6 she was seen by a different GP who recognised the sig- nificance of her symptoms and referred her urgently. Case History

Acute first severe headache causes: ✤ SAH ✤ Meningitis ✤ Thunderclap ✤ CVST ✤ Migraine ✤ Majority primary headaches

Headache in A & E ✤ 2% of all visits ✤ 1% of these have SAH ✤ 10-15% of these SAH no neurology

G43,44,R51 H/A & SAH AdmissionsPatients England North East SAH England SAH N East339327

Rates 500k ❖ Non-specific headache 2-3 per day ❖ SAH 1.5 per week

Acute headache in CHSFT ✤ Annual number A&E attendances 670 ✤ 2 per day ✤ 36 >1 visit ✤ admission 456 ✤ 36>1 admission ✤ total bed days 842 ✤ total cost 150*842= £126,300

Delay in diagnosis ❖ GP education ❖ ED education ❖ HEE & competencies ❖ Protocols agreed & universal

Delay in process ❖ Access to CT 90% ❖ LP 75% ❖ Neurosurgery ❖ 24/7 working

Reorganisation of assessment units ❖ Availability of facilities 24/7 ❖ Availability of neurology 24/7 ❖ Achieved for stroke

Summary ❖ National integrated pathway ❖ Designated acute neuro units alongside stroke 24/7 ❖ Rehabilitation in DGH stroke unit ❖ Agreed at a regional level -senates ❖ Consultant to consultant referrals if possible ❖ 6 monthly audit to refine pathway

SAH ✤ Instant, generalised ✤ onset within few secs or 1min 75% ✤ gradually worse ✤ nausea & vomiting ✤ photophobia

Headache of SAH ✤ Suddenness, abruptness ✤ flash, hit on the head, bolt from the blue, just like that etc ✤ Sudden often used to describe H/A coming over 30 mins ✤ NOT SEVERITY ✤ When did it start? ✤ Neck stiffness takes 3-12 hrs to appear

Others ✤ Mens/encephalitis/CVST ✤ Gradual onset ✤ focal signs, seizures, papilloedema ✤ Migraine not the first ✤ Thunderclap = SAH but negative investigation