Patients presenting with a primary or secondary complaint of acute headache represent a persistent source of malpractice claims and lawsuits.¹ They are especially costly, because they can result in death and lifelong disability.² Although the value of noncontrast computed tomography (NCCT) brain imaging for evaluating headache is undisputable, over-reliance on a negative NCCT can lead to a serious miss and a lawsuit.3,⁴ Consider adding more historical detail, a National Institutes of Health Stroke Scale (NIHSS), meningeal signs, and funduscopic examination to the physical exam in selected patients with acute headache.

Legal Background

In studies of misdiagnosis and closed lawsuits, over-reliance on a negative CT and missing history and physical exam elements are cited as causes.¹ The most common claims are for subarachnoid hemorrhage, stroke, cerebral venous sinus thrombosis (CVST), and meningitis/encephalitis.⁴ The most common theory advanced by the plaintiff is that, had the defendant done a more thorough history and physical (H&P) exam, it would have triggered further testing and the condition would have been caught. It can be a challenge to convince a jury that additional physical examination should not have been done when a catastrophic result occurs.

Medical Background

Given the unmodifiable constraints of time and resources in the emergency department, it is not possible to perform every element of the H&P.5 However, there are selected features clinicians may choose to add to better cover subtle or atypical presentations.

Historical Features

Delineating the exact time of onset and rapidity of onset are particularly valuable with regard to subarachnoid hemorrhage. If the timing can be accurately established at less than six hours, a negative CT comes very close to ruling out subarachnoid hemorrhage (SAH).³ Detailing that the time to maximal onset exceeds one hour is also helpful.⁶ The presence or absence of neurological symptoms, including posterior circulation features such as dizziness, imbalance, and new visual disturbances can help point to stroke as a potential cause, because approximately 40 percent of posterior circulation strokes present with headache as a primary or secondary complaint.⁷ Fourteen percent of anterior circulation strokes do so as well.⁸

NIHSS

The NIHSS can be a valuable tool, because a significant percentage of these conditions can present with subtle neurological deficits, particularly stroke. Approximately 10 percent of SAH, a significant percentage of strokes, and roughly 17 to 43 percent of CVST can present with both acute headache and subtle neurological deficits.^9,10 In the first four to six hours, the NIHSS may be more sensitive than MRI for stroke, because an NIHSS score of zero does not exclude stroke and early diffusion-weighted MRI may be falsely negative.^11,12 I don’t recommend NIHSS for every patient with acute headache, but in selected cases it’s of high value and can be performed quickly.