Headaches are one of the most common symptoms that neurologists evaluate. Although most are caused by primary disorders, the list differential diagnoses is one of the longest in all of medicine, with over 300 different types and causes. The cause or type of most headaches can be determined by a careful history supplemented by a general and neurologic examination. Reasons for obtaining neuroimaging include medical indications as well as anxiety of patients and families and medico-legal concerns. In the era of managed care, concerns over deselection and negative capitation may dissuade the physician from ordering even a medically indicated scan. The yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low. Combining the results of multiple studies performed since 1977 for a total of 3026 scans reveals the overall percentages of various pathologies as: brain tumors, 0.8%; arteriovenous malformations, 0.2%; hydrocephalus, 0.3%; aneurysm, 0.1%; subdural hematoma, 0.2%; and strokes, including chronic ischemic processes, 1.2%. EEG is not useful in the routine evaluation of patients with headache. Similarly, the yield of neuroimaging in the evaluation of migraine is quite low. Combining the results of multiple studies performed since 1976 for a total of 1440 scans of patients with various types of migraine, the overall percentages of various pathologies are: brain tumor, 0.3%; arteriovenous malformation, 0.07%; and saccular aneurysm, 0.07%. WMA have been reported on MRI studies of patients with all types of migraine, with a range from 12% to 46%. The cause of WMA in migraine is not certain. Cerebral atrophy has been variable reported as more frequent and no more frequent in migraineurs compared with controls. The "first or worst" headache has a long list of possible causes and always includes the possibility of acute subarachnoid hemorrhage. Headaches--especially the sentinel type caused by SAH--often are misdiagnosed. The probability of detecting an aneurysmal hemorrhage of CT scans performed at various intervals after the ictus is: day 0.95%; day 3, 74%; 1 week, 50%; 2 weeks, 30%; and 3 weeks, almost nil. The location of a ruptured saccular aneurysm often is suggested by the predominant site of the SAH. The probability of detecting xanthochromia with spectrophotometry in the CSF at various times after a subarachnoid hemorrhage is: 12 hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, more than 70%; and 4 weeks, more than 40%. The management of thunderclap headaches with normal CT scan and CSF examinations is controversial. Most patients have a benign course but an unruptured saccular aneurysm occasionally may be responsible for the headache. MR angiography may be a reasonable test to obtain instead of a cerebral arteriogram in many of these cases. About 30% to 90% of patients have headaches of various types and causes after mild head injury. Although most headaches are relatively benign, perhaps 1% to 3% of these patients have life-threatening pathology, including subdural and epidural hematomas, that are detected on CT and MRI scans. Headaches caused by subdural hematomas can be nonspecific. When new- onset headaches begin in patients over the age of 50 years, the physician always should consider whether it may be a secondary headache disorder requiring specific diagnostic testing and treatment. Up to 15% of patients 65 years and over who present to neurologists with new- onset headaches may have serious pathology such as stroke, TA, neoplasm, and subdural hematoma. Headaches are the most common symptom of TA, reported by 60% to 90%. The only over the temple. The diagnosis of TA is based on a high index of clinical suspicion that usually but not always is confirmed by laboratory testing. The erythrocyte sedimentation rate can be normal in 10% to 36% of patients with TA. A superficial temporal artery biopsy can give a false-negative result in 5% to 44% of patients

Headache represents one of the most common somatic complaints seen in the emergency department, accounting for 1% to 3% of all emergency department visits. Although most headaches seen in the emergency department are benign, as many as 10% of all headaches are secondary to an underlying pathologic condition. The emergency physician is well- trained to exclude stoke, subarachnoid hemorrhage, and meningitis as potential causes of headache. This article focuses on seven unusual headache syndromes, all of which are associated with significant morbidity and mortality. Particular emphasis is placed on clinical features and diagnostic modalities of choice

The choice of objectives and content in neurologic education should be informed by evidence from patient outcomes and errors. Malpractice claims are proposed as one data source, although they only partially reflect health outcomes. Epidemiologic, statewide data suggest some provisional priorities for key topics and training targets, but require further research to assess their value for guiding neurologic education

This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted

Sometimes neurologists face malpractice suits that occur from cases when a patient's diagnosis is not foreseeable. This requires that neurologists make clear and accurate notes on patient charts to show current reasoning in expectation that eventually, the neurologist may have to defend his or her misdiagnosis in court. Two current trial cases are presented in this article. You decide, which case should be considered malpractice or maloccurrence?

There is often a fine line between medical malpractice and maloccurrance. Physicians need to develop techniques and skills that enhance the patient-physician relationship based on honesty and informed consent. Documentation and proper maintenance of medical records is demanded by the current legal and health care systems. Failure to follow programs which maintain the integrity of patients' records often has negative consequences. The cases discussed illustrate areas in which the neurologist has come into conflict with the legal system

Legal issues that may arise in neurodiagnostic testing are reviewed briefly. This article focuses on applications of medical malpractice law with respect to negligence in selection, conduct, and interpretation of tests. The impact of the doctrine of informed consent is considered both in the context of malpractice law and human subjects research. The article concludes with a short exposition on enterprise liability and diagnostic tests, indicating the ways in which the growing role of corporations in medical practice may prompt changes in how claims for test-related medical injuries are processed. This article aims to convey an appreciation of how the law attempts to reduce test-related harms by imposing liability on individuals and organizations

A careful and complete headache history supplemented by a neurologic and general physical examination, as appropriate, enables the astute physician to diagnose most headaches correctly without diagnostic testing. When indications are present (see Box 1), some headache patients with a normal physical examination require testing even though the yield may be low. Failure to test may result in misdiagnosis of potentially serious and life-threatening causes of headaches, such as brain tumors, chronic meningitis, SAH, and temporal arteritis

A retrospective study was performed at two teaching hospitals--one in the United States and one in Canada--to determine the results of computed tomography (CT) examinations of the head in patients with nontraumatic headache. Of 1111 examinations performed over a 3-year period, 120 (10.8%) demonstrated an acute intracranial abnormality, such as hemorrhage, infarction or tumour; the frequency of such abnormalities was highest among inpatients and subjects over 40 years of age. Cranial and extracranial abnormalities, such as sinusitis and metastases to the calvarium, were found in 40 (3.6%) of the cases. Chronic abnormalities, such as cerebral atrophy or remote infarction, were the most significant findings in 202 (18.2%) of the cases. The cost of finding each case of acute intracranial abnormality was $5962 (US); for subarachnoid hemorrhage among patients in the emergency department, it was $15,837 (US)

Intracranial tumors affecting the visual system are a source of malpractice claims involving optometrists. Signs and symptoms of disease, such as papilledema, optic atrophy, decreased visual acuity, headache, loss of visual field, acute onset incomitant strabismus, and gradually worsening coordination, should prompt optometrists to rule out the possibility of an underlying intracranial lesion. Appropriate optometric and medical evaluation should be provided. Co-management of care with other health care practitioners should be scrupulously coordinated and documented