A pilot survey of decisions by acute medicine staff after thunderclap headache

INTRODUCTION AND AIMS: Traditionally, neurologically pristine patients with a thunderclap headache are investigated with a non-contrast computed tomography (CT) brain scan, which if negative is followed by a lumbar puncture (LP) to exclude important secondary causes, particularly subarachnoid haemorrhage (SAH). However, misdiagnosis of such patients is still a cause of significant human and financial cost and a regular reason for medical litigation. This study explores the approach of emergency medicine and acute medicine clinicians to the investigation of a patient with thunderclap headache.

METHODS: Clinicians were invited to complete an online survey based on a clinical vignette of a 45-year-old man presenting with a thunderclap headache who had a pristine neurological examination.

RESULTS: A total of 160 clinicians responded. The majority (89%) elected to perform a non-contrast CT brain as their first investigation, though five clinicians discharged the patient without investigation. If the CT was negative, only 84% would then proceed to LP, but 20% would undertake this investigation before 12 hours from headache onset.

CONCLUSIONS: Most clinicians investigate neurologically intact patients with thunderclap headache following a CT/LP strategy, but deviations from recommended practice are common.