This document outlines pathways for managing head injuries and headaches in the emergency department. It discusses indications for CT scanning in head injuries and criteria for admission versus discharge. Red flags are provided for various headache presentations that may indicate serious underlying causes like stroke, meningitis or brain tumors. Guidelines are given for assessing children with headaches and evaluating HIV-positive patients. The importance of thorough history taking, physical exams, following proper protocols, consulting seniors as needed and considering social factors is emphasized for safely managing these patients.

1. Head injury &
Headache pathways
Dr Rashid Abuelhassan,
MBBS, MRCEM
A&E Specialty Doctor
City Hospital

2. Outline
• Why important
• Indications to scan
• The pathway
• The disposition
• The head instruction
• Norse referral + Regional Trauma Desk (RTD)
• Headache pathway
• The disposition
• How to find guidelines for further reading

3. Indications ?

5. 75 year, Sandra, found on the floor next to the
stairs. Can’t recall what happened and now
has no complain o/e minor cut wound on
forehead.

6. Head injury pathways

7. pathway

13. Admit who ?
• Abnormalities on imaging → NORSE
• GCS <15 after imaging regardless .
• Scan not done/reported *
• Continuing worrying signs .
• factors of concern (e.g. drug or alcohol intoxication,
other injuries, shock, suspected non-accidental
injury, meningism, cerebral spinal fluid leak,
Collapse ? Cause)
• No responsible carer at home

18. Discharge advice
• Always verbal + written
before discharge .
• Discuss details
• (Use of language line)
• MECC
• refer to GP for follow-up
within 1 week after
discharge

19. DO NOT
• stay at home alone for the first 24
hours.
• take any alcohol or drugs.
• sleeping pills, sedatives.
• contact sport for at least 3 wks .
• return to school, college or work until
completely recovered.
• drive a car, motorbike or bicycle or
operate machinery.
Do :
• stay within easy reach of a telephone
and medical help.
• plenty of rest and avoid stressful
situations.

21. • GCS ≤13 or HR mech.
→resus → paediatric
trauma call 2222.
• Manual In Line
Stabilisation
• GCS< 8 →Hyperacute
transfer to BCH

23. CT scan normal. let’s DISCHARGE …

24. Admission should be considered
for the following:
• Ongoing severe headache or
vomiting
• Persistent abnormal neurology
• Comorbidity ie Haemophilia,
Diabetes mellitus, Epilepsy
• Social concerns (lack of parental
ability to monitor)
• Suspicion of NAI

26. Headache pathways

27. Adult Headache in ED

30. AMAA AMU
ADMIT TO AMU
FURTHER ASSESMENT

31. THE HEADACH PATHWAY

33. HEADACHE PRESENTAIONS
A) WITH REDUCED GCS/ FOCAL
NEUROLOGY / NECK STIFFNESS
• Stroke, SAH, Ch SDH, ↑ICP,
• Meningitis,Encephalitis, Cerebral malaria
• HTN encephalopathy
B) Headache With Local Signs
• Acute sinusitis
• AACG
• Giant cell arteritis
• Temperomandibular joint dysfunction
• Cervicogenic headache
• Mucormycosis *

34. C) Headache + Papilloedema
• Accelerated HTN
• HTN encephalopathy
• Cerebral venous sinus thrombosis
• Idiopathic intracranial hypertension
• ↑ ICP causes
D)Headache with Fever (no focal Neurology
• Meningitis
• Encephalitis
• Subarachnoid haemorrhage
• Systemic infectious disease (malaria
and typhoid )
• Local infection (e.g. sinusitis)

35. SUBARACHNOID HAEMORRHAGE
Clinical Features
• Sudden, severe headache that reaches
maximal intensity within minutes (97% of
cases)*
• May be associated with:
• syncope
• seizure
• nausea/vomiting
• meningismus*
• Retinal hemorrhage (may be the only clue in comatose patients)
Sentinel bleed headache 6-20 days
before serious SAH in 30-50% of
patients

36. Carotid or vertebral arterial
dissection
• Unilateral headache
accompanied by neck pain.
• May follow neck manipulation
• accompanied by other signs
(TIA, stroke, Horner syndrome or
pulsatile tinnitus)

37. HIV-positive patient:
Depends on CD4 T cell count
• >500 Usual causes
• 200–500 Usual causes & HIV encephalopathy
• <200 Usual causes &
• Cerebral lymphoma
• Toxoplasmosis
• Cryptococcal meningitis
• Tuberculous meningitis
• Progressive multifocal leucoencephalopathy

38. Remember Others types
• Drug-related E.g. nitrates,
nicorandil, dihydropyridine
calcium antagonists
• Toxin exposure E.g. carbon
monoxide poisoning
• Medication-misuse
headache
• Cerebral venous sinus
thrombosis

39. Red flag Headache in adults
• Sudden onset
• Worst ever
• Dramatic change in pattern
• Malignancy/immunocompromised
• Headache on exertion
• New onset>50 years
• Reduced gcs/focal signs

41. Child Headache in ED

42. Red flag Headache*
• Persistent
• Recurrent vomiting
• Balance, coordination and walking
problems
• Abnormal eye movements, blurred
vision, diplopia
• Epileptic seizures
• Recent behavioral change
• Abnormal head position
• Delayed or arrested puberty,
declining growth trend
Red flag Headache = space occupying lesions

43. Summery
• Do the head trauma proforma
• Always remember C-Spine
• Do the headache proforma
• Call for senior help is always better
• Use language line if you need it
• NAI suspected → initiate safeguarding

44. Any Questions ??