Headaches in the emergency department –a survey of patients’ characteristics, facts and needs

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Abstract

Background and aim

Headache is very often the cause for seeking an emergency department (ED). However, less is known about the different diagnosis of headache disorders in the ED, their management and treatment. The aim of this survey is to analyse the management of headache patients in two different ED in Europe.

Methods

This retrospective survey was performed from September 2018 until January 2019. Patients were collected from the San Luca Hospital, Milan, Italy and the Ordensklinikum Barmherzige Schwestern, Linz, Austria. Only patients with a non-traumatic headache, as the primary reason for medical clarification, were included. Patients were analysed for their complexity and range of examination, their diagnoses, acute treatment and overall efficacy rate.

Results

The survey consists of 415 patients, with a mean age of 43.32 (SD ±17.72); 65% were female. Technical investigation was performed in 57.8% of patients. For acute treatment non-steroidal-anti-inflammatory drugs (NSAIDs) were the most used, whereas triptans were not given. A primary headache disorder was diagnosed in 45.3% of patients, being migraine the most common, but in 32% of cases the diagnosis was not further specified. Life-threatening secondary headaches accounted for less than 2% of cases.

Conclusions

The vast majority of patients attending an ED because of headache are suffering from a primary headache disorder. Life-threatening secondary headaches are rare but seek attention. NSAIDs are by far the most common drugs for treating headaches in the ED, but not triptans.

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Most cited references 14

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Red and orange flags for secondary headaches in clinical practice

Thien Do, Angelique Remmers, Henrik Winther Schytz … (2019)

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

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Medical consultation for migraine: results from the American Migraine Study.

R. Lipton, Michael W. Stewart, D. Simon (1998)

Migraine headaches are often disabling but usually responsive to treatment. Nonetheless, many people with migraine never consult a doctor for headaches. In a sample of the US population, we sought to determine the proportion of active migraineurs who ever consulted a doctor for headache and to identify the headache characteristics and sociodemographic factors associated with consulting. A mailed questionnaire survey was sent to 15,000 US households, selected from a panel to be representative of the US population. Of 20,468 eligible respondents ranging in age from 12 to 80 years, 2479 met a case definition for migraine. We mailed a second questionnaire to all migraineurs identified on the first survey and achieved a 69.4% response rate. The second survey assessed headache characteristics, patterns of medical care use, medication use, and method of payment for health care. Sixty-eight percent of female and 57% of male migraineurs reported having ever consulted a doctor for headache. Consultation was more likely with increasing age and in women who ever married. In females, several headache characteristics including pain intensity, number of migraine symptoms, attack duration, and disability were associated with consultation. Of those who never consult, 61% report severe or very severe pain and 67% report severe disability or the need for bed rest with their headaches. The results of this survey indicate that a significant proportion of migraine sufferers never consult doctors for their headaches. Given that a large proportion of persons who never consult report high levels of pain and disability, these data suggest that there are opportunities to appropriately increase health care utilization for migraine. Given that 40% of migraineurs who have ever consulted do not report a physician diagnosis of migraine, there is a need to improve headache diagnosis and/or doctor-patient communication about migraine.

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European headache federation consensus on technical investigation for primary headache disorders

D. D. Mitsikostas, M Ashina, Stephen Craven … (2016)

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.

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Author and article information

Contributors

Christian Lampl:

ORCID: http://orcid.org/0000-0003-4340-3486

christian.lampl@ordensklinikum.at

Journal

Journal ID (nlm-ta): J Headache Pain

Journal ID (iso-abbrev): J Headache Pain

Title: The Journal of Headache and Pain

Publisher: Springer Milan (Milan )

ISSN (Print): 1129-2369

ISSN (Electronic): 1129-2377

Publication date (Electronic): 5 November 2019

Publication date PMC-release: 5 November 2019

Publication date Collection: 2019

Volume: 20

Issue: 1

Electronic Location Identifier: 100

Affiliations

[1 ]ISNI 0000 0004 1757 9530, GRID grid.418224.9, Department of Neurology-Stroke Unit and Laboratory of Neuroscience, , Istituto Auxologico Italiano, ; Milan, Italy

[2 ]Department of Neurorehabilitation, Yaroslavl regional clinical hospital of War Veterans, Yaroslavl, Russian Federation

[3 ]ISNI 0000 0001 2176 9917, GRID grid.411327.2, Department of Neurology, Medical Faculty, , Heinrich-Heine-University, ; Duesseldorf, Germany

[4 ]80th Battalion of Medical Corps, General Ioannis Makrygiannis Camp, Pyli, Kos, Greece

[5 ]General Hospital of Grevena, Grevena, Greece

[6 ]ISNI 0000 0004 1757 123X, GRID grid.415230.1, Regional Referral Headache Centre, , Sant’ Andrea Hospital, ; Rome, Italy

[7 ]ISNI 0000 0001 2097 9138, GRID grid.11450.31, Department of Medical, Surgical and Experimental Sciences, , University of Sassari, ; Rome, Italy

[8 ]ISNI 0000 0001 2155 0800, GRID grid.5216.0, 1st Neurology Department, Aeginition Hospital, Medical School, , National and Kapodistrian University of Athens, ; Athens, Greece

[9 ]Headache Medical Center Linz, Ordensklinikum Barmherzige Schwestern, Seilerstaette 2-4, 4020 Linz, Austria

Author information

Christian Lampl http://orcid.org/0000-0003-4340-3486

Article

Publisher ID: 1053

DOI: 10.1186/s10194-019-1053-5

PMC ID: 6833179

PubMed ID: 31690261

SO-VID: 7f359709-f6ed-4b68-8266-bb4ac6393480

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 8 July 2019

Date accepted : 13 October 2019

Custom metadata

ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: headache,emergency department,primary headache,migraine,secondary headache

Data availability:

ScienceOpen disciplines: Anesthesiology & Pain management

Keywords: headache, emergency department, primary headache, migraine, secondary headache

Headaches in the emergency department –a survey of patients’ characteristics, facts and needs

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Irish Journal of Paramedicine

Most cited references 14

Red and orange flags for secondary headaches in clinical practice

Medical consultation for migraine: results from the American Migraine Study.

European headache federation consensus on technical investigation for primary headache disorders

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