1. 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

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

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

4. G43,44,R51 H/A & SAH AdmissionsPatients England7152867207 North East46224294 SAH England64246193 SAH N East339327

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

6. 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

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

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

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

10. 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

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

12. 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

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