Abstract
The aim of this study was to measure prevalence, to describe underlying etiologies, and to assess radiological findings, focusing on significant intracranial abnormality (sICA). This was a prospective study of unselected adult patients admitted to the emergency department (ED) in a tertiary care hospital where all presenters were systematically interviewed about their symptoms. We attributed nontraumatic headache with neuroimaging to four groups: Normal or no new finding, extracranial abnormality, insignificant intracranial abnormality, or significant intracranial abnormality. sICA was defined as “needing acute therapy”, “needing follow-up neuroimaging”, or “clinically important neurological disorder”. Among 11,269 screened ED presentations, the prevalence of nontraumatic headache was 10.1% (1132 patients). Neuroimaging (cCT and/or cMRI) was performed in 303 patients. Seventy (23.1% of scanned; 6.2% of all headache patients) patients had sICA. Etiologies were cerebrovascular disease (56%), intracranial bleeding (17%), tumors (14%), infection (9%), and others (6%). Short-term outcome was excellent, with 99.3% in-hospital survival in patients with and 99.4% in patients without neuroimaging, and 97.1% in sICA; 1-year survival in outpatients with neuroimaging was 99.2%, 99.0% in outpatients without, and 88.6% in patients with sICA. Factors associated with sICA were age, emergency severity index (ESI) of 1 or 2, Glasgow coma score (GCS) under 14, focal neurological signs, and a history of malignancy. Prevalence of headache and incidence of sICA were high, but survival after work-up for nontraumatic headache was excellent in the 94% patients without sICA. Due to the incidence of sICA, extensive indication for neuroimaging in headache patients is further warranted, particularly in patients with risk factors.
Highlights
Headache is a frequent complaint and the majority of the population is occasionally affected [1]
We have previously described that headache is among the most prevalent symptoms in emergency department (ED) patients, affecting more than one out of six patients, if patient-reported symptoms are not screened, or filtered by physicians [12]
As the majority of ED patients report more than one symptom [13], and headache patients report a median of four symptoms, it is highly likely that previous studies have underreported headache, potentially due to inclusion bias and the physician filter
Summary
Headache is a frequent complaint and the majority of the population is occasionally affected [1]. As the majority of ED patients report more than one symptom [13], and headache patients report a median of four symptoms (often in combination with nonspecific complaints [14,15]), it is highly likely that previous studies have underreported headache, potentially due to inclusion bias and the physician filter. Constructs such as “chief complaint” or “main symptom” heavily rely on several steps of selection and reduction of information [16]—physicians tending to focus on frequent and specific presenting symptoms [17]. Outcomes, underlying conditions, and the yield of radiological work-up in headache has rarely been conducted in prospective all-comer populations
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