$70.8M awarded in neuro misdiagnosis—how aggressively do you work up a headache?
Industry Buzz
The first thing that should come to mind as a clinician when evaluating headache in the ER is the SNOOP criteria. This will help you assess for potential red flags in a patient with a headache.
—Rajesh Burela, DO, neurology resident physician at Northwell Health in Poughkeepsie, NY
In September 2025, a Hillsborough County jury awarded $70.8 million to a 38-year-old woman who suffered a devastating stroke after being discharged from Tampa General’s Brandon Healthplex ED without neuroimaging. []
The woman came to the hospital by ambulance, with a headache she described as the “worst she had ever had.” Yet she received only labs, a COVID test, and a “headache cocktail” before being sent home about four hours later. No CT or neurology consult was obtained by the nurse practitioner on the case.
Within about 30 hours, the patient developed weakness and numbness, and suffered a stroke. She was admitted to Tampa General’s main campus, where subsequent imaging showed cerebral venous sinus thrombosis (CVST). The stroke left her with blindness, paralysis, and cognitive impairment.
The jury found the nurse practitioner negligent and ruled that the health system was vicariously liable. The patient was left permanently disabled. TeamHealth, the contractor for the nurse practitioner, has indicated it will appeal the verdict.
What does the latest guidance say?
Various sets of guidelines offer protocols for evaluating acute headache, including the use of neuroimaging.
Acute nontraumatic severe headache
ACEP’s 2024 policy alert recommends using the Ottawa Subarachnoid Hemorrhage (SAH) Rule for risk stratification (high sensitivity, low specificity). []
If risk persists after a negative non-contrast CT, either LP or CT angiography should be done to safely rule out SAH, via shared decision-making.
Subarachnoid hemorrhage
AHA/ASA’s 2023 guideline underlines rapid imaging and timely neurosurgical involvement when SAH is suspected. []
Cerebral venous sinus thrombosis
The 2024 AHA statement recommends MRI/MRV as the first-line investigation to confirm cerebral venous thrombosis (CVT), with CT/CTV as a reasonable alternative when resources are limited or pretest probability is lower. []
Related: Mary can't find relief from her migraines—Can you help?How physicians decide when to escalate
Alok Mohta, MD, a board-certified physician, notes that headaches caused by CVT have no specific characteristics. They can be unilateral, sudden (even thunderclap), or migraine-like.
Therefore, it's always essential to keep a broad range of differentials in mind and escalate promptly.
Red flags include a patient’s complaint of a new-onset “first” or “worst” headache; exertional onset; neck stiffness; focal deficits; pregnancy/postpartum; thrombophilia; or anticoagulation or estrogen use.
All these symptoms should push clinicians toward immediate CT ± CTA or CTV and a low threshold for obtaining a neuro consult. []
Rajesh Burela, DO, a neurology resident physician at Northwell Health in Poughkeepsie, NY, emphasizes the need for a structured framework.
“The first thing that should come to mind as a clinician when evaluating headache in the ER is the SNOOP criteria. This will help you assess for potential red flags in a patient with a headache," Dr. Burela says.
SNOOP, Dr. Burela explains, stands for:
Systemic symptoms, such as fever, weight loss, or cancer
Neurologic symptoms or signs, such as focal deficits or altered mental status
Onset that is typically a sudden, abrupt headache or a "thunderclap" headache
Older age at onset
Previous headache hystery
All of these, or any other abnormalities that may stand out from a typical headache, should warrant swift consultation from a neurologist, according to Dr. Burela.
Pamela Tambini, MD, medical director at Engage Wellness, similarly cites the signs that warrant quick action.
“When a patient presents with severe or atypical headache—including a sudden worst headache of their life, vision deficits, altered consciousness, papilledema, fever, or neck stiffness, history of cancer or HIV, onset after exertion, or any thunderclap or rapidly escalating pain—this calls for urgent escalation and immediate imaging. Typically, start with a CT first, then an MRI if the CT is clean but suspicion remains.”
