1. Headache Dr Sarah Robinson Consultant Emergency Medicine Southampton Headache

2. Life-threatening Causes: Subarachnoid haemorrhage Meningitis/ encephalitis Space Occupying Lesion Temporal Arteritis Pre-eclampsia Headache

3. Other diagnoses to consider Venous sinus thrombosis Dissection Hypertensive encephalopathy Glaucoma/ iritis CO poisoning Headache

4. Diagnoses you will not make in the ED Migraine Coital cephalgia Exertional headache Headache

5. History Site Onset Character Radiation Associated symptoms Timing Exacerbating/ relieving Severity Headache

6. Red flags: history Thunder-clap headache Worse headache ever Syncopal episode Altered mental state Onset with exercise Worse on waking Seizure Headache

7. Beware... Elderly Immunocompromised Previous neurosurgery (shunts) Headache

8. Red flags: signs Fever Altered mentation Focal neurology Meningism Headache

9. Examination Appearance Photophobic Rash Temperature BP Kernigs/ Brudzinski Focal neuro deficit Visual fields Fundoscopy Headache

10. Subarachnoid haemorrhage Up to 50% initially misdiagnosed – 15% re-bleed early – 40% re-bleed in next 4/52 1 in 10 ED Pts with thunderclap headache Headache

11. SAH: aetiology Family history Smoking Hypertension Alcohol Cocaine Headache

12. SAH: history Most thunderclap Worse headache ever Seizure at onset Neck stiffness Headache

13. SAH: signs May be normal Decreased GCS III CN palsy Retinal haemorrhages Headache

15. SAH: investigations CT – 98% sensitive if within 12 hours LP Headache

16. SAH: Management in ED ABCD defG Analgesia Anti-emetic D/W senior CT and refer Headache

17. SAH: pitfalls “not worse ever headache” “Headache improved with cocodamol” “CT was negative” Headache

18. Meningitis Headache Fever Neck stiffness Altered mental state Sepsis/ SIRS Headache

19. Temporal arteritis Older Scalp tenderness Jaw claudication ESR Headache

20. Summary Thunderclap headache? Senior review Never diagnose migraine in ED Headache