Nontraumatic Headache Research Articles

Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study

BackgroundPeople presenting to the ED with acute severe headache often undergo investigation to exclude subarachnoid haemorrhage (SAH). International guidelines propose that brain imaging within 6 hours of headache onset can...

Emergency department CT scan utilization and findings in geriatric patients presenting with non-traumatic headache

Background & Objective: In geriatric patients, headache is a common reason for emergency department (ED) visits. Because secondary headaches are more common in geriatric patients than in younger patients, the former should be carefully excluded at presentation. In this study, we aimed to investigate the role of brain computed tomography (CT) in geriatric patients presenting to the ED with non-traumatic headache, the indications for imaging, the CT findings, and factors associated with detection of pathology. Methods: Patients aged 65 years and older who presented to the ED with headache between January 1, 2023 and December 31, 2023, who underwent a brain CT scan, and who had complete data were included in the study. Patients with an intracranial mass, acute-subacute ischemic findings, intraparenchymal and subarachnoid hemorrhage, and cerebral edema on brain CT scan were considered as having significant pathology. Results: The study included 384 patients. CT scan was normal in 61.2% of the patients and 10.4% had significant pathology. It was observed that 24.5% of the patients underwent CT scan for prolonged headache and 19.3% for severe headache. Logistic regression analysis showed that severe headache, loss of consciousness, anticoagulant use, neurological deficit, and elevated blood pressure at presentation were predictors of the detection of significant pathology on CT scan. Conclusion: In conclusion, 10.4% of geriatric patients presenting to the emergency department with headache have significant CT findings, and the impact of these findings on the emergency management of patients cannot be ignored. Incorporating these findings into clinical decision-making guidelines could improve the effectiveness of emergency management protocols by facilitating rapid and specific diagnostic interventions for geriatric patients presenting with headache.

Utility of cranial MRI in non-traumatic headache patients with prior negative head CT within 1 month

To investigate the importance of additional cranial magnetic resonance imaging (cMRI) in non-traumatic headache patients with a prior negative head computed tomography (CT) examination within 1 month. This retrospective study analysed 162 adult patients with non-traumatic headache who underwent cMRI within 1 month of a negative initial head CT at the emergency department (ED). The diagnostic yield and false-referral rate were analysed according to the revisit duration (early [≤1 week] versus late [>1-4 weeks] revisits), patient care settings (ED versus outpatient clinics [OPC]), and clinical variables. Subsequent patient management change (PMC), such as admission and treatment (AT) or outpatient clinic treatment (OT), were also investigated. The overall diagnostic yield of cMRI was 17.3% (28/162) and the false-referral rate was 1.2% (2/162). The diagnostic yield of cMRI was significantly different according to the patient care settings (ED, 24.7% [21/85] versus OPC, 9.1% [7/77]; p=0.02). The diagnostic yield was highest in the ED-early-revisit group (25.4% [18/71]), 45% (9/20) in those with systemic signs, and 46.7% (14/30) in those with symptom change. Among patients with positive cMRI findings, 90% (27/30) received AT and 3.3% (1/30) received OT. Among OPC-revisit-negative cMRI patients, PMC occurred in 0% (0/50). The diagnostic yield of cMRI was relatively high for headache patients who revisited the ED earlier, especially in those with systemic signs or symptom change. Most positive cMRI cases experienced PMC. Negative cMRI in OPC-revisit patients might help clarify the benign nature of a condition.

The Magnitude of Physical and Sensory Impairments in Post-traumatic and Non-traumatic Cervicogenic Headaches: A Comparative Study.

Background Cervicogenic headaches can significantly deteriorate the quality of life of patients and decrease their productivity. Few studies have been conducted to assess the magnitude of physical impairments among patients with non-traumatic and post-traumatic cervicogenic headaches. Therefore, this study was conducted to examine and compare the magnitude of cervical physical impairments among patients with post-traumatic cervicogenic headaches in contrast to patients with non-traumatic cervicogenic headaches, migraine, and a group of sex- and age-matched controls who did not have headaches. Methodology This was a comparative study. A total of 104 patients and 30 sex- and age-matched controls were included. The patients were stratified into three groups: post-traumatic cervicogenic headaches (n = 42), non-traumatic cervicogenic headaches (n = 30), and migraines (n = 32). The cervical active range of motion and proprioception were assessed using a goniometer, the craniovertebral angle was measured while the heads of the subjects rested in a comfortable position, the strength of the cervical flexors and extensors was assessed using a hand-held dynamometer, and endurance of the short cervical flexors was assessed while the subjects were in a supine position with no pillow. Skin roll tests were performed in the trapezius and mandibular areas, and pain was measured using the McGill Pain Questionnaire-Short Form. Results Patients in the post-traumatic cervicogenic headache group reported a significantly higher number of headache days (p < 0.001) compared to the controls, patients with migraines, and those with non-traumatic cervicogenic headaches. Patients with post-traumatic cervicogenic headaches showed a significant reduction in total rotation, flexion and extension, lateral bending, and craniovertebral angle compared to the controls, patients with migraines, and those with non-traumatic cervicogenic headaches. On the other hand, the controls endured significantly longer and had stronger neck flexors and extensors compared to the patients in the migraine, non-traumatic, and post-traumatic cervicogenic headache groups, respectively. Patients with post-traumatic cervicogenic headaches significantly reported higher affective and total pain compared to the controls and patients in the migraine group. Conclusions Patients with post-traumatic cervicogenic headaches had significant deficits in the cervical active range of motion in the different planes, endurance, and strength of cervical flexors and extensors compared to the controls and patients with migraine and non-traumatic cervicogenic headaches. Similarly, patients with post-traumatic cervicogenic headaches reported higher affective pain compared to the controls and patients with migraines. The results of this study indicated that patients with post-traumatic cervicogenic headaches have significantly higher physical impairments compared to patients with non-traumatic cervicogenic headaches. These differences warrant caution when combining data from patients with non-traumatic and post-traumatic cervicogenic headaches.

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study.

Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r = -0.248). In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.

Characteristics of patients who visited emergency departments for headache in South Korea: A descriptive cross-sectional study.

This study aimed to describe the characteristics of adult patients who visit emergency departments (EDs) for non-traumatic headache in South Korea. Little is known about East Asian patients who visit EDs for headache. This observational, descriptive, cross-sectional study retrospectively analyzed 2019 National Emergency Department Information System data, including age, sex, co-occurring fever, symptom duration, insurance type, transportation mode, ED level, triage level, ED visit time, specialist consultations at the ED, disposition from the ED, and outcomes. The proportion of patients with a life-threatening secondary headache and the diagnostic codes were investigated. A total of 227,288 patients were observed in this study, accounting for 2.2% (227,288/10,238,360) of all ED visits. Females (63.1%; 143,493/227,288) visited EDs more than males, and patients aged 50-60 years (21.0%; 47,637/227,288) visited most frequently. A total of 61.5% (93,789/151,494) of ED visits were within 24 h after headache onset, and 57.6% (131,056/227,288) of visits were assigned to non-urgent triage levels. The most frequent discharge codes were "R51: Headache (not better specified)" from the ED and ward, and "I60: Subarachnoid hemorrhage" from the intensive care unit. The rate of migraine diagnosis was 7.2% (16,471/227,288). A total of 3.1% (7153/227,288) of patients were diagnosed with life-threatening secondary headaches, most commonly subarachnoid hemorrhage (1.2%; 2744/227,288) and cerebral infarction (0.6%; 1341/227,288). In South Korea, the characteristics of patients who visited the ED for non-traumatic headache were not very different from those in existing studies; however, patients tended to visit EDs early and be classified as non-urgent, and emergency physicians tended to enter the diagnosis code "R51: Headache (not better specified)", resulting in a much lower rate of migraine diagnoses. Non-urgent early visitors coded with "R51" may include those who have not yet been diagnosed with primary headache and have not been treated, but who need further research. Not applicable.

Non-traumatic headache as an emergent conditions-role of MRI

Background: Non-traumatic headaches are a prevalent neurological issue in emergency departments, affecting about 1–4% of patients. These headaches can be classified as primary or secondary, with the latter posing a risk of severe complications. Neuroimaging is critical for identifying secondary headache causes, with CT traditionally used to reveal abnormalities in 13–15% of patients. MRI offers superior soft tissue imaging without ionizing radiation, yet its use in emergency settings remains under-explored. Risk scoring systems have been developed to guide imaging decisions, focusing on patient age, neurological deficits, and other symptoms as predictors of intracranial pathology. Aim: This review aims to evaluate the role of MRI in diagnosing non-traumatic headaches in emergency settings and to analyze clinical guidelines for its appropriate use. Methods: A retrospective investigation was conducted on emergency patients presenting with non-traumatic headaches, analyzing MRI findings, demographics, and clinical presentations. Results: MRI identified significant abnormalities in approximately 20% of patients. Factors such as age, smoking status, and signs of infection correlated with abnormal findings, while a history of migraine appeared protective. The predictive model for identifying significant imaging outcomes showed limited clinical utility. Conclusion: MRI is a valuable tool in assessing non-traumatic headaches in emergency departments, particularly in high-risk patients.

S100B serum level: A relevant biomarker for the management of non-traumatic headaches in emergency care?

BackgroundThe diagnostic of primary or secondary headaches in emergency units is mostly based on brain imaging, which is expensive and sometimes hardly accessible. An increase in serum S100B protein has already been found in several neurological conditions inducing brain damage. The objective of this study was to assess the diagnostic performance of S100B serum assay to distinguish primary and secondary headaches among patients with non-traumatic headaches in the emergency department. MethodsThis was a phase 2, prospective, monocentric diagnostic study. Eighty-one adult patients with non-traumatic headaches in the emergency department were included. In addition to the usual management, a blood assay of the S100B protein was performed in the emergency department, as well as a brain MRI between 48 and 96 h if not performed during the initial management. The primary or secondary headache diagnosis was made at one month by an expert committee, blindly of the results of the S100B assay. The primary outcome was the blood assay of the S100B protein. ResultsThere was 63 patients for analysis in the primary headache group and 17 in the secondary headache group. The S100B protein assay was significantly higher in secondary headaches than primary headaches, with an AUC of the ROC curve of 0.67. The optimal threshold of 0.06 μg.L−1 allowed to obtain those diagnostic characteristics: sensitivity 75% [48; 93], specificity 62% [48; 74], PPV 35% [20; 54] and NPV 90% [76; 97]. The association between the S100B protein level and the onset of pain was significantly higher for patients with headaches <3 h. ConclusionThe assay of the S100B protein could be useful in the management of this pathology in emergencies. Future studies taking into account dosing time and etiologies could be conducted in order to refine its use in practice.

Comparison of the Effect of Therapeutic Exercise Protocol With and Without Kinesiotype and Manual Therapy on Pain and Disability and Muscle Function of Men With Cervicogenic Headache

Background and Aims Headache is one of the most common problems in adults and almost 47% of the world's population suffer from some kind of headache. High percentage of these headaches come from neck muscles these are called cervicogenic headaches. The purpose of this study is Comparison of the effect of comprehensive therapeutic protocol with and without manual treatment and kinesiotaping on pain and disability, postural and electrical activity of some neck muscles in men with non-traumatic cervicogenic headache. Methods 43 men aged 35 to 55 years with non-traumatic cervicogenic headache were selected for this study and randomly divided into four groups.Forward head angle, pain and disability and power of neck superficial muscle activation measured by using the photogrammetry, neck pain and disability scale (NPDS) and surface electromyography respectively in pre-test and after six weeks in post-test. Statistical methods, Shapiro-wilk and then repeated measures ANOVA and one-way ANOVA and paired t-test, repeated measure variance and finally and Bonferroni were used (α≤0.05). Results The results showed a significant decrease in pain and disability, forward head angle and also a decrease in the activity of the superficial neck muscles in the experimental groups after six weeks of intervention. (P=0.00). Comparing the above three experimental groups, the comprehensive exercise therapy group with manual therapy had the highest statistical significance in reducing pain and disability, reducing the angle of head forward and reducing the activity of superficial neck muscles. (P=0.00). Conclusion comprehensive exercise therapy intervention with manual therapy had the greatest effect on improving the symptoms of men with non-thromatic cervicogenic headache.

Diagnostic yield of emergency MRI in non-traumatic headache

PurposeNon-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache.MethodsIn this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes.ResultsIn total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance.ConclusionAlthough emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.

Adding eosinophil count to EMERALD rules predicts subarachnoid haemorrhage better in emergency department.

Subarachnoid haemorrhage (SAH) clinical decision rules can provide successful results in the differential diagnosis of non-traumatic headache. The aim of this study is to investigate whether a laboratory parameter that can be added to clinical decision-making rules can better predict subarachnoid haemorrhages in patients presenting to the emergency department with headache. We conducted a retrospective cohort study between March 2017 and March 2019. Patients over the age of 18 who admitted to the emergency department with non-traumatic, acute headache last 14days before admission and evaluated by imaging and laboratory studies were included in the study. A total of 867 patients were included and 141 of them had SAH. In detecting the SAH, Ottawa SAH rule sensitivity (85.1%), specificity (47.1%), positive predictive value (PPV) (23.8%) and negative predictive value (NPV) (94.2%), and for EMERALD SAH, rule sensitivity (96.4%), specificity (43.2%), PPV (24.8%) and NPV (98.4%). In the regression analysis, statistically significant result was obtained to exclude the diagnosis of SAH with the decrease in the eosinophil value (cutoff < 0.085 10^3/µL, OR: 0.011, 95% CI: 0.001-0.213, p = 0.003). When eosinophil value was added to EMERALD SAH rule, it provided a 100% of sensitivity, a 38.4% of specificity, a 24% of PPV and a 100% of NPV in detecting the SAH. EMERALD SAH rule plus eosinophil, which offers 100% sensitivity and NPV for predicting SAH in adult non-traumatic headaches, may be recommended as a successful and practical decision rule for clinical use according to the Ottawa and EMERALD SAH rule.

The relationship between abnormal intracranial findings in brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache: a prospective cohort study.

ObjectiveThis study aimed to investigate the relationship between abnormal intracranial findings on brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache in the emergency department (ED).MethodsThis was a single-center prospective observational study of patients admitted to the tertiary ED with complaints of nontraumatic headache between May 1, 2016 and September 1, 2016. Anticoagulant or antiplatelet drug use by the patient was recorded. Brain computed tomography (CT) results were categorized into two groups, abnormal results (CT positive) and no pathologic results (CT negative), and compared. The CT positive group included any pathological signs in the brain and the negative group was considered a normal read. A logistic regression analysis was used for evaluating the association of antiplatelets and anticoagulants with abnormal CT findings.ResultsOf the 837 patients with nontraumatic headaches, 157 (18.8%) patients who underwent brain CT scanning were included. The mean age of the patients was 44.4±16.7 years. Eighty-eight (56.1%) of the patients were women. Of the 29 (18.4%) patients using antiplatelets or anticoagulants, 16 (55.2%) were in the CT positive group. There was a statistically significant difference between both groups in terms of drug use compared to the CT negative group (P<0.001). Factors affecting CT results were examined in logistic regression analysis and a statistically significant difference was found in the detection of positive results in antiplatelet or anticoagulant drug users (adjusted odds ratio, 2.478; 95% confidence interval, 1.006–6.102; P=0.048).ConclusionThe use of antiplatelets or anticoagulants in patients admitted to the ED with nontraumatic headache is associated with an increased risk of abnormal intracranial results in brain CT.

Diagnostic Values of Red Flags and a Clinical Prediction Score for Emergent Intracranial Lesions in Non-Traumatic Pediatric Headaches.

Introduction: Diagnosis of emergent intracranial lesions that require emergency treatment either medically or surgically in non-traumatic pediatric headaches is important. Red-flag signs and symptoms are commonly used as justification for neuroimaging; however, evidence on its diagnostic values is limited. The study aims to identify diagnostic values of red-flags and develop a clinical prediction score to help improve the diagnostic yield of neuroimaging. Methods: A retrospective review of 109 pediatric patients from 2006 to 2020 who presented with a non-traumatic headache was conducted. A clinical prediction score from red flags was developed using multivariate logistic regression. Discriminatory ability was examined using the area under the receiver operating characteristic curve. Results: A total of 51 patients were diagnosed with emergent intracranial lesions. Four potential clinical red flag predictors were identified: (1) acute onset (less than 3 months), (2) altered conscious state, (3) focal motor abnormality, and (4) and ocular/pupillary abnormality or squint. A clinical prediction score was developed with good discriminatory properties (0.84). Conclusions: Clinical predictor scores from these four red flags may play an important role in maximizing neuroimaging and proper management for pediatric patients with non-traumatic headaches. Future validation studies are needed and could guide referrals and optimize the use of neuroimaging for these patients.

Carbon monoxide: raising awareness of the silent killer in the emergency department

BackgroundCarbon monoxide (CO) is an odourless gas produced by the incomplete combustion of carbon containing materials. CO poisoning causes a range of symptoms of which headache is the most common,...

Evaluation and treatment of acute migraine in the emergency department

Headache is one of the most common neurological complaints admitted to emergency deprtment (ED). In different studies, the proportion of patients admitted to the emergency room due to nontraumatic headache is around 0.5-4.5%. Most of the patients with headache (22-55%) are benign primary headaches. Among primary headaches, migraine is the most common reason for admission to the emergency department. As can be seen in all ages, it usually occurs at a young age. The male to female ratio is 3: 1 and its prevalence is estimated to be 5% in men and 15-17% in women. According to WHO's list of common diseases, loss of functionality and disability, migraine attacks are in the fifth place in women and among the first twenty diseases in men. Therefore, it is very important to manage migraine attacks in the emergency room. When we look at the previous reviews on this subject, we can deduce that they are not always appropriate for emergency physicians, since most of the articles are quite long and detailed. Our aim in this review is to give enough information in the light of current information about migraine headache that emergency physicians will need.

S100ß protein for non-traumatic subarachnoid hemorrhage diagnosis

IntroductionThe S100ß protein (PS100ß) is a biomarker, which has demonstrated its importance in diagnoses ruling out intracranial hemorrhages in people with light head traumas This study aims to evaluate if the PS100ß presents an interest in the diagnostic strategy for subarachnoid hemorrhages (SAH). MethodsProspective non-randomized multicentric study in three hospitals from October 2018 to January 2020. Every patient who came into the emergency department for an intense non-traumatic headache lasting less than 3 h received an PS100ß assay and a non-injected head computed tomography (CT) scan. The primary endpoint was the number of patients with a diagnosis of SAH on the head CT scan with a PS100ß level of under 0.10 μg/L. Results60 patients were included and five patients had a SAH. Four patients had an SAH with a PS100ß level lower than 0.10 μg/L and one patient had an SAH with a PS100ß level higher than 0.10 μg/L. The negative predictive value for the PS100ß with a discriminating threshold less than or equal to 0,10 μg/L in the diagnosis ruling out SAH was 93% [IC 95%: 0,86–1]. ConclusionS100ß protein assay with a discriminating threshold of 0,10 μg/L does not demonstrate any interest in the diagnostic strategy for non-traumatic SAH.

Management of patients presenting to the emergency department with sudden onset severe headache: systematic review of diagnostic accuracy studies

ObjectiveAdvances in imaging technologies have precipitated uncertainty and inconsistency in the management of neurologically intact patients presenting to the Emergency Department (ED) with non-traumatic sudden onset severe headache with a...

Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes

Background and Aim: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. Methods: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. Results: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. Conclusions: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

Comparison of the efficacy of intranasal ketamine versus intravenous ketorolac on acute non-traumatic headaches: a randomized double-blind clinical trial

IntroductionNon - traumatic headaches are one of the most common causes of referral to hospital emergency. This study aimed to compare the efficacy of intranasal ketamine and intravenous ketorolac on acute non-traumatic headaches.MethodsThis randomized and double-blind clinical trial was conducted in 2019. One hundred and forty samples were randomly divided into intranasal ketamine (A) and intravenous ketorolac (B). Group (A) received ketamine intranasal (0.75 mg/kg, max 75 mg), and group B received intravenous ketorolac (30 mg). Headache severity was measured on arrival, 30, 60, and 120 min after intervention with Visual Analogue Scale (VAS). The side effects were recorded an hour after the intervention.ResultThe mean difference of pain intensity 30, 60, and 120 min after the intervention between the two groups was statistically significant (p < 0.001). In the first 30 min, significant changes were observed in the VAS levels of the two groups. These changes were significantly greater in the intranasal ketamine group (p < 0.001). Side effects such as fatigue, dizziness, general discomfort, nausea, increased heart rate, and hypertension were significantly higher in the ketamine group (p < 0.05).ConclusionIntranasal ketamine and intravenous ketorolac both effectively reduced headaches. However, more analgesic effects of intranasal ketamine in a short time can be considered as a selective approach to reducing headaches.Trial registrationIRCT20180108038276N3, Registered 29 September 2019.Ethics committee reference numberIR.KUMS.REC.1398.068.

Head computed tomography findings in relation to red flag signs among patients presenting with non-traumatic headache in the emergency services

Introduction: Non-traumatic headaches are a common presentation in emergency services. A non-contrast computed tomography (NCCT) scan of the head is done when there is suspicion of intracranial abnormalities. Such intracranial abnormalities are indicated by "red flag" signs. This study aimed to determine the prevalence of intracranial abnormalities in patients with non-traumatic headaches and its association with the red flag signs. Method: A total of 106 patients presenting with a non-traumatic headache to the emergency services of TUTH from Aug 2019 to Aug 2020, who underwent head CT were included in the study. The association of head CT positivity with the presence of red flag signs was studied by bivariate analysis using the chi-square test or Fisher exact test. Result: Among 106 patients, 46(43.4%) were male and the rest were female. The mean age of the patient was 43.69+17.46. All the patients who had positive findings in head CT had at least one red flag sign. Out of 16 red flag signs included in this study, 10 signs showed a significant association (p&lt;0.05) with head CT positivity. These are sudden onset of headache, age of onset &gt;50 years, significant change in pattern or severity of headache, “worst headache ever”, vomiting, neck stiffness, seizures, altered sensorium, papilledema, and focal neurological deficits. Conclusion: Red flag signs of headache are helpful to determine whether head CT is needed or not to look for significant intracranial abnormalities in a patient presenting with non-traumatic headache in an emergency.