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Evaluating HIV-Infected Patients With Headache: Who Needs Computed Tomography?


  • Allen L. Gifford MD,

    1. From the Health Services Research and Development Program, VA San Diego (Calif) Healthcare System and the Department of Medicine, University of California San Diego School of Medicine, La Jolla (Dr. Gifford);
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  • Frederick M. Hecht MD

    1. Positive Health Program and HIV Section, San Francisco (Calif) General Hospital and the University of California San Francisco School of Medicine (Dr. Hecht). At the time of the study, Dr. Gifford was a Robert Wood Johnson Clinical Scholar at Stanford University.
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Address all correspondence to Dr. Allen L. Gifford, VA San Diego Healthcare System, University of California San Diego, 3350 La Jolla Village Drive (111N-1), San Diego, CA 92161.


Objective.—To empirically test a clinical prediction rule for evaluating HIV-infected patients complaining of headache and to identify those at low risk for intracranial mass lesion who do not need immediate computed tomography of the head.

Design.—Two retrospective clinical cohorts of HIV-infected patients clinically evaluated for headache.

Methods.—To describe the headache clinical outcomes, medical records were abstracted from all HIV-infected patients evaluated for headache with computed tomography of the head at two urban hospitals. Patients were categorized as low, intermediate, or high risk based on clinical criteria (focal neurological signs, altered mental status, history of seizure) and immune status (CD4 lymphocytes≤200/μL). Records were abstracted from a second unselected cohort of HIV-infected outpatients with headache who were all treated and followed in primary care (N=101).

Results.—Of 101 unselected HIV-infected outpatients followed in primary care after headache, 1% (95% confidence interval [CI], 0% to 6%) had a treatable intracranial lesion. Of 364 HIV-infected patients with headache sent for evaluation with computed tomography of the head, the rate of any abnormality was zero in the low-risk group (95% CI, 0% to 10%; n=35); 9% in the intermediate-risk group (95% CI, 2% to 16%; n=242); and 21% in the high-risk group (95% CI, 12% to 29%; n=87).

Conclusion.—Most HIV-infected patients with headache may be treated with analgesics and followed up clinically. Those without focal neurological signs, altered mental status, seizure, or decreased CD4 lymphocytes are unlikely to have intracranial mass lesions.