Benign Headache Research Articles

Correlation between benign joint hypermobility syndrome and headache in children and adolescents

BackgroundBenign Joint Hypermobility Syndrome (BJHS) is a most common hereditary connective tissue disorders in children and adolescents. This study aimed to investigate the prevalence and subtypes of headache in children with BJHS.MethodsThis observational-analytical study was conducted in a case-control setting on school children aged 7 to 16 years in 2021–2023 in Isfahan, Iran. Students were examined for BJHS using Beighton criteria by a pediatric rheumatologist. Headache disorder was diagnosed according to the Child Headache-Attributed Restriction, Disability, and Social Handicap and Impaired Participation (HARDSHIP) questionnaires for child and adolescent and International Classification of Headache Disorders (ICHD-III).ResultsA total of 4,832 student (mean age 10.3 ± 3.1 years), 798 patients with BJHS and 912 healthy children were evaluated. The probability of headache in children aged 7–11 with hypermobility was 3.7 times lower than in children aged 12–16 with hypermobility (P = 0.001). The occurrence of headache in children with BJHS was more than the control group (P = 0.001), and the probability of headache in children with BJHS was 3.7 times higher than in healthy children (P = 0.001). Migraine was the most common headache type reported of total cases. The probability of migraine in children with BJHS was 4.5 times higher than healthy children ( P = 0.001).ConclusionThis study showed a significant correlation between BJHS and headache (especially migraine) in children and adolescents.

Clinical Characteristics and Appropriateness of Investigations in Children With Headaches at the Emergency Department

BackgroundIdentifying the cause of headaches in pediatric emergency departments (PEDs) can be challenging due to the lack of comprehensive research. This study aims to identify the frequency, characteristics, and unnecessary diagnostic procedures of patients with headaches in the PED setting. MethodsA six-month cross-sectional study was conducted at the PED of Alexandria University Children's Hospital, including all children with headaches. Children were classified as having primary headache (PH), secondary benign headache (SBH), and secondary serious headache (SSH) according to predetermined criteria. Logistic regression was employed to analyze the risk factors associated with SSH. ResultsA total of 164 visits to the PED were recorded, out of a total of 22,662 visits, accounting for approximately 0.72% of all visits and 1.17% of the total number of children admitted. PH was the most common cause, accounting for 61.0% of cases, followed by SSH with 24.4%, whereas SBH was the least common with 13.4%. Abnormal neurological examination (odds ratio, 53.752 [1.628 to 1774.442], P = 0.026∗) was found to have a strong and statistically significant association with SSH in the multivariate analysis. Regarding the appropriateness of the investigations conducted, it was found that over half (66.5%) of the cases had unnecessary neuroimaging, with 52% of these cases being children with PH. ConclusionsHeadaches in children are commonly reported during visits to the PED. PH was the most prevalent, followed by SSH, whereas SBH was the least common. Many of the children received inaccurate first diagnoses and performed unnecessary laboratory tests, neuroimaging, and other tests, mostly electroencephalography.

Abstract WP283: Association of High-Risk Cardioembolic Sources on Cardiac CT With Acute Ischemic Stroke: A Case-Control Study

Background: Cardiac CT is increasingly used to detect a source of cardioembolism in stroke patients. We assessed the association between sources of embolism on cardiac CT, which were predefined as high-risk, and acute ischemic stroke. Methods: We analyzed data from Mind the Heart, a prospective, single-center, observational cohort study, and included consecutive patients with a suspected stroke who underwent ECG-gated cardiac CT during the initial stroke imaging protocol. Cases were patients with a final diagnosis of acute ischemic stroke (AIS), established by an adjudication committee. Controls were patients with stroke mimics (SMi). We excluded patients with a transient ischemic attack. Cardiovascular radiologists diagnosed structural high-risk sources of cardioembolism on cardiac CT according to predefined criteria. High-risk sources on cardiac CT were: cardiac thrombi, signs of endocarditis, recent myocardial infarction, prosthetic valve abnormalities, atrial myxomata and signs of rheumatic valvular disease. We used logistic regression, adjusting for age, sex, history of atrial fibrillation, and history of myocardial infarction. Results: Of 607 included patients, 452 had AIS (74%, median age 72, 59% male) and 155 had a SMi (26%, median age 70, 46% male). Diagnoses in the SMi group were: seizures (45/155, 29%) peripheral vestibulopathy (22/155, 14%), functional neurologic symptoms (16/155, 10%), benign headache disorder (8/155, 5%), intoxication (7/155, 5%), and other diagnoses (57/155, 37%). Cardiac CT detected a structural high-risk cardioembolic source in 52/452 AIS patients (12%) and in 5/155 SMi patients (3%, three patients with seizures, one with peripheral vestibulopathy and one with traumatic brain injury, aOR: 4.1, 95%CI 1.7-12.1). Cardiac thrombi were the most commonly observed high-risk sources of embolism and were detected in 38 (8%) AIS patients and in 2 (1%) SMi patients (aOR 7.0, 95%CI 2.1-43.9). Discussion and conclusion: A high-risk source of cardioembolism was detected on cardiac CT four times more often in patients with acute ischemic stroke than in patients with a stroke mimic. These data substantiate the clinical relevance of using acute CT to search for sources of cardioembolism in ischemic stroke patients.

(094) Sexual Emergencies in Women

Abstract Introduction Sexual emergencies in female patients are more common than people think. They represent medical curiosities more than pathologies for which we should be prepared to treat. This review and the presentation of our cases shows how extensive and important is this area in the medical practice and why every single physician should be prepared to confront them. Gynecologist, surgeons, sexologists, and ER physicians are familiarized with some of the sexual emergencies in women that called the attention of the medical community. However, the broad spectrum of those disorders is not well-known. Objective 1. Show the magnitude of sexual emergencies in women nationally and internationally. 2. Describe how they can vary according with the place, culture, and societies. 3. To learn the methods of diagnosis and treatment of these ample variety of conditions. Methods Based on the multiple cases seen in the ER of our facility, an extensive review of the literature was done, and the cases are presented to show the magnitude, variety, and diversity of cases in the different areas of the medical field. Results The review includes: I. The common coital emergencies in neurology (benign coital headache, subarachnoid hemorrhage, intracerebral bleeding, subdural hemorrhage, cerebral vascular accidents), urology (ureterovesical foreign bodies, obstructive uropathies), cardiology (sudden cardiac death, myocardial infarction), gynecology (vaginal lacerations and/or evisceration and death with/without previous gynecological surgeries), obstetrical (postpartum dyspareunia secondary or not to episiotomy or vaginal lacerations; postcoital preterm labor), immunological (local or systemic, anaphylactic allergic reactions). II. Common autoerotic emergencies in gastroenterology (foreign objects in rectum, vagina, oropharyngeal/mandibular lesions), as well as “body packers” cases (swallowed latex balloons for smuggling in the GI tract, rectum, or vagina). III. Sexual assault IV. Sexual dysfunction: Hyperactive arousal disorders (compulsive hunt for orgasms with/without attempt or real suicide, hypersexuality related to SSRI use). V. Sociosexual issues: Killings for jealousy during sex, infidelity, castration like Lorena Bobbitt case. Conclusions The epidemiology of these pathologies varies from country to country, and state to state, and includes women of any age, race, religion, and culture. Finally, a review of these diagnostic methods and treatment are presented. Disclosure No

(448) Sexual Emergencies

Abstract Introduction Urologist, gynecologist, surgeons, sexologists, and ER physicians are familiarized with some of the sexual emergencies that called the attention of everybody. However, the broad spectrum of those disorders is not well-known. Objective 1. Show the magnitude of sexual emergencies in an important hospital of South Florida. 2. Show the magnitude of sexual emergencies nationally and internationally. 3. Describe how they can vary according with the place, culture, and societies. 4. To learn the methods of diagnosis and treatment of these ample variety of conditions. Methods Based on the multiple cases seen in our ER in Hialeah Hospital in Miami, Florida, extensive review of the literature was done, and the cases are presented to show the magnitude, variety, and diversity of cases in the different areas of the medical field. Results The review includes: I. The common coital emergencies in neurology (benign coital headache, subarachnoid hemorrhage, intracerebral bleeding, subdural hemorrhage, cerebral vascular accidents), urology (penile fracture, priapism, preputial tears, penile vessel rupture, penile strangulation, penile necrosis, ureterovesical foreign bodies, epididymitis., obstructive uropathies), cardiology (sudden cardiac death, myocardial infarction), gynecology (vaginal laceration and/or evisceration with/without previous gynecological surgeries), obstetrical (postpartum dyspareunia secondary or not to episiotomy or vaginal lacerations; postcoital preterm labor), immunological (local or systemic, anaphylactic allergic reactions). II. Common autoerotic emergencies in gastroenterology (foreign objects in rectum, vagina, oropharyngeal/mandibular lesions), as well as “body packers” cases (swallowed latex balloons for smuggling in the GI tract, rectum, or vagina). III. Sexual assault IV. Sexual dysfunction: Hyperactive arousal disorders (compulsive hunt for orgasms with/without attempt or real suicide, hypersexuality related to SSRI use). V. Sociosexual issues: Killings for jealousy during sex, infidelity, castration like Lorena Bobbitt case. gynecologicalgynecological Conclusions The epidemiology of these pathologies varies from country to country and includes subjects of any age, sex, race, religion, and culture. Finally, a review of these diagnostic methods and treatment are presented. Disclosure No

Vaccine associated benign headache and cutaneous hemorrhage after ChAdOx1 nCoV-19 vaccine: A cohort study

ObjectivesFatal complications have occurred after vaccination with ChAdOx1 nCoV-19, a vaccine against Covid-19. Vaccine-induced immune thrombotic thrombocytopenia (VITT) with severe outcome is characterized by venous thrombosis, predominantly in cerebral veins, thrombocytopenia and anti-PF4/polyanion antibodies. Prolonged headaches and cutaneous hemorrhages, frequently observed after the ChAdOx1 nCoV-19 vaccine, have therefore caused anxiety among vaccinees. We investigated whether these symptoms represent a mild form of VITT, with a potential for aggravation, e.g. in case of a second vaccination dose, or a different entity of vaccine complications Materials and methodsWe included previously healthy individuals who had a combination of headache and spontaneous severe cutaneous hemorrhages emerging after the 1st dose of the ChAdOx1 nCoV-19 vaccine. Twelve individuals were found to meet the inclusion criteria, and a phone interview, cerebral MRI, assessment of platelet counts, anti PF4/polyanion antibodies and other laboratory tests were performed. ResultsNone of the symptomatic vaccinees had cerebral vein thrombosis, hemorrhage or other pathology on MRI. Platelet counts were within normal range and no anti-PF4/polyanion platelet activating antibodies were found. Moreover, vasculitis markers, platelet activation markers and thrombin generation were normal. Furthermore, almost all symptoms resolved, and none had recurrence of symptoms after further vaccination with mRNA vaccines against Covid-19. ConclusionsThe combination of headaches and subcutaneous hemorrhage did not represent VITT and no other specific coagulation disorder or intracranial pathology was found. However, symptoms initially mimicking VITT demand vigilance and low threshold for a clinical evaluation combined with platelet counts and D–dimer.

Post COVID-19 vaccination headache: A clinical and epidemiological evaluation.

This study aimed to assess the prevalence and clinical characteristics of headaches, in particular secondary headaches. This observational study was performed at the ASST Spedali Civili of Brescia, Italy. Visits to the Emergency Department (ED) and subsequent hospitalizations regarding a new or worsening headache in the 16 days following the administration of the COVID-19 vaccine between January 2021 and January 2022 were recorded and compared with those of January 2019-January 2020. The ratio between ED admissions due to headaches and total ED admissions was significantly higher in 2021 compared with 2019 (4.84% vs. 4.27%; p < 0.0001). Two-hundred and eighty-nine ED headache admissions (10.8% of all ED headache admissions) were time-correlated to the COVID-19 vaccination, of which 40 were hospitalized in order to exclude a symptomatic etiology. At discharge, 32 patients had a diagnosis of benign headache not attributed to any cranial/extracranial disorder and eight patients of secondary headache, whose diagnoses were the following: Headache attributed to cranial and/or cervical vascular disorder (n = 4); headache attributed to nonvascular intracranial disorder (n = 2); headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure (n = 1); and painful lesions of the cranial nerves (n = 1). The headache most frequently reported by patients had migraine-like characteristics: the localization was predominantly frontal or temporal, the pain was described as throbbing and severe in intensity and it was frequently accompanied by nausea/vomit, and photo-phonophobia. Over half-regardless of the final diagnosis-of hospitalized patients had a history of primary headaches. Following the spread of COVID-19 vaccination, the number of ED admissions due to headaches significantly increased. However, less than 14% of all the ED visits due to a headache time-correlated to the COVID-19 vaccination were actually hospitalized, with most patients documenting a benign headache, possibly related to the generic side effects of the vaccination. Only 8/40 hospitalized patients were diagnosed with a secondary headache. These benign headaches would actually fulfill diagnostic criteria for 8.1 Headaches attributed to the use of or exposure to a substance (ICHD-3), although, at the time being, it does not include vaccines as possible substances.The headache migraine-like characteristics' reported by most patients could suggest activation of the trigeminovascular pathway by all the cytokines and other pro-inflammatory molecules released following the vaccination.

Short-term stroke risk after emergency department treat-and-release headache visit.

To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

The diagnostic values of red flags in pediatric patients with headache

BackgroundHeadache is a common complaint in childhood and adolescence. Differentiating benign primary headaches from ominous secondary headaches is often difficult. Clinicians usually seek red flags to determine the need for neuroimaging. We aimed to evaluate the diagnostic values of red flags in pediatric headaches. MethodsWe retrospectively reviewed the medical records of 1510 pediatric patients (1470 with primary headache, 40 with secondary headache) presenting with headache and underwent neuroimaging from two centers between March 2010 and December 2019. ResultsThe secondary-headache group exhibited significantly higher frequencies of abnormal neurologic signs/symptoms (40.0% vs 6.8%, p < 0.001), Valsalva maneuver/exercise-induced headache (15.0% vs 4.9%, p = 0.004), headache with vomiting (35.0% vs 17.9%, p = 0.006), and onset under age 6 (25.0% vs 10.3%, p = 0.003) than the primary-headache group, with the following positive likelihood ratio (PLR): 5.88, 3.06, 1.96, and 2.42, respectively. The sensitivity values were as follows: abnormal neurologic signs/symptoms (16/40, 40.0%), headache with vomiting (14/40, 35.0%), onset under age 6 (10/40, 25.0%), and Valsalva maneuver/exercise-induced headache (6/40, 15.0%). The overall sensitivity for ominous secondary headaches requiring surgical treatment was 86.2% (25/29). ConclusionsCertain red flags, including abnormal neurologic signs/symptoms, Valsalva maneuver/exercise-induced headache, headache with vomiting, and onset under age 6, were more prevalent in the secondary-headache group; nonetheless, their sensitivity values and PLR were relatively low. Notwithstanding, considering these red flags’ high overall sensitivity for ominous secondary headaches, neuroimaging in patients presenting these red flags should rely on careful follow-up of symptom progression.

Evaluation and treatment of acute migraine in the emergency department

Headache is one of the most common neurological complaints admitted to emergency deprtment (ED). In different studies, the proportion of patients admitted to the emergency room due to nontraumatic headache is around 0.5-4.5%. Most of the patients with headache (22-55%) are benign primary headaches. Among primary headaches, migraine is the most common reason for admission to the emergency department. As can be seen in all ages, it usually occurs at a young age. The male to female ratio is 3: 1 and its prevalence is estimated to be 5% in men and 15-17% in women. According to WHO's list of common diseases, loss of functionality and disability, migraine attacks are in the fifth place in women and among the first twenty diseases in men. Therefore, it is very important to manage migraine attacks in the emergency room. When we look at the previous reviews on this subject, we can deduce that they are not always appropriate for emergency physicians, since most of the articles are quite long and detailed. Our aim in this review is to give enough information in the light of current information about migraine headache that emergency physicians will need.

Abstract WMP55: Short-term Stroke Risk After Emergency Department Treat-and-release Headache Visit

Introduction: When a stroke hospitalization follows soon after an Emergency Department (ED) treat-and-release visit for non-specific neurological complaints, a diagnostic error may have occurred. In this study, we sought to evaluate potential stroke misdiagnoses after ED treat-and-release headache visits. Methods: We conducted a retrospective cohort study using state-wide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard ICD codes, we identified adult patients discharged home from the ED with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of back pain or renal colic (negative control cohorts). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic), defined using validated ICD codes. We used Cox proportional hazards modeling to assess the relationship between the index ED visit reason and stroke hospitalization adjusting for demographics and vascular risk factors. Results: We identified 1,458,904 patients with an ED treat-and-release headache visit; mean age was 41 (SD: 17) and 70% were female. A total of 2,636 (0.18%) headache patients were hospitalized for stroke within 30 days. Stroke risk was higher among headache patients compared to patients diagnosed with renal colic (HR: 2.7; 95% CI, 2.3-3.1) or back pain (HR: 3.8; 95% CI, 3.6-4.1; Figure). Among patients &lt;40 years of age, stroke risk was even higher among headache as compared to back pain (HR: 10; 95% CI, 7.7-13.1); no strokes occurred in renal colic patients &lt;40 years of age. Conclusion: Approximately 1 in 500 patients discharged home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was 3-4 times higher after an ED visit for headache compared to back pain or renal colic. There may be opportunities to reduce diagnostic error among patients with ED visits for headache, particularly for those &lt;40 years of age.

The Interplay Between Neuroinfections, the Immune System and Neurological Disorders: A Focus on Africa.

Neurological disorders related to neuroinfections are highly prevalent in Sub-Saharan Africa (SSA), constituting a major cause of disability and economic burden for patients and society. These include epilepsy, dementia, motor neuron diseases, headache disorders, sleep disorders, and peripheral neuropathy. The highest prevalence of human immunodeficiency virus (HIV) is in SSA. Consequently, there is a high prevalence of neurological disorders associated with HIV infection such as HIV-associated neurocognitive disorders, motor disorders, chronic headaches, and peripheral neuropathy in the region. The pathogenesis of these neurological disorders involves the direct role of the virus, some antiretroviral treatments, and the dysregulated immune system. Furthermore, the high prevalence of epilepsy in SSA (mainly due to perinatal causes) is exacerbated by infections such as toxoplasmosis, neurocysticercosis, onchocerciasis, malaria, bacterial meningitis, tuberculosis, and the immune reactions they elicit. Sleep disorders are another common problem in the region and have been associated with infectious diseases such as human African trypanosomiasis and HIV and involve the activation of the immune system. While most headache disorders are due to benign primary headaches, some secondary headaches are caused by infections (meningitis, encephalitis, brain abscess). HIV and neurosyphilis, both common in SSA, can trigger long-standing immune activation in the central nervous system (CNS) potentially resulting in dementia. Despite the progress achieved in preventing diseases from the poliovirus and retroviruses, these microbes may cause motor neuron diseases in SSA. The immune mechanisms involved in these neurological disorders include increased cytokine levels, immune cells infiltration into the CNS, and autoantibodies. This review focuses on the major neurological disorders relevant to Africa and neuroinfections highly prevalent in SSA, describes the interplay between neuroinfections, immune system, neuroinflammation, and neurological disorders, and how understanding this can be exploited for the development of novel diagnostics and therapeutics for improved patient care.

Update on diagnosis and differential diagnosis of vestibular migraine.

Vestibular migraine (VM) is considered the most common cause of spontaneous episodic vertigo and the second most common cause of vertigo. However, without a biomarker or a complete understanding of the pathophysiology, VM remains underrecognized and underdiagnosed. Therefore, definite diagnostic criteria are urgently needed. Meanwhile, VM should be clearly differentiated from other similar diseases. This paper may help clinicians improve the diagnostic rate of VM and reduce the rate of misdiagnosis. A PubMed search was performed using the following terms: vestibular migraine, migraine-associated vertigo/dizziness, migraine-related vertigo, migraine-related vestibulopathy, benign recurrent vertigo, vertiginous migraine, migraine, headache, vertigo, dizziness, and diagnosis. This paper also summarizes the diagnostic criteria and differential diagnoses of VM. The diagnosis of VM is based on the symptoms, degree, frequency, and duration of the vestibular episodes, a history of migraine, and the temporal association of migraine symptoms with vestibular episodes in at least 50% of cases, while ruling out what may be due to other reasons. In addition to vestibular symptoms and migraine, transient auditory symptoms, nausea, vomiting, and susceptibility to motion sickness may also be associated with VM. Thus, VM should be differentiated from other diseases such as Meniere's disease, benign paroxysmal positional vertigo, migraine with brainstem aura, vestibular neuritis, posterior circulation ischemia, multiple lacunar infarction, vestibular paroxysmia, motion sickness, and episodic ataxia type 2. Only if the diagnostic criteria of VM and differential diagnosis can be mastered clearly, we can make a definite diagnosis and treat patients properly.

Epidemiology, investigation, management, and outcomeofheadache in emergency departments (HEADstudy)-A multinational observational study.

To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. An international, multicenter, observational, cross-sectional study was conducted over one calendar month in 2019. Participants were adults (≥18years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re-presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. We enrolled 4536 patients (67hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%-75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non-SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti-inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In-hospital mortality was 0.3% (11/4526). Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.

Cerebrovascular disease hospitalizations following emergency department headache visits: A nested case-control study.

Delayed diagnosis of cerebrovascular disease (CVD) among patients can result in substantial harm. If diagnostic process failures can be identified at emergency department (ED) visits that precede CVD hospitalization, interventions to improve diagnostic accuracy can be developed. We conducted a nested case-control study using a cohort of adult ED patients discharged from a single medical center with a benign headache diagnosis from October 1, 2015 to March 31, 2018. Hospitalizations for CVD within 1year of index ED visit were identified using a regional health information exchange. Patients with subsequent CVD hospitalization (cases) were individually matched to patients without subsequent hospitalization (controls) using patient age and visit date. Demographic, clinical, and ED process characteristics were assessed via detailed chart review. McNemar's test for categorical and paired t-test for continuous variables were used with statistical significance set at ≤0.05. Of the 9157 patients with ED headache visits, 57 (0.6%, 95% confidence interval [CI]=0.5-0.8) had a subsequent CVD hospitalization. Median time from ED visit to hospitalization was 107days. In 25 patients (43.9%, 25/57) the CVD hospitalization and the index ED visit were at different hospitals. Fifty-three cases and 53matched controls were included in the final study analysis. Cases and controls had similar baseline demographic and headache characteristics. Cases more often had a history of stroke (32.1% vs. 13.2%, p=0.02) and neurosurgery (13.2% vs. 1.9%, p=0.03) prior to the index ED visit. Cases more often had less than two components of the neurologic examination documented (30.2% vs. 11.3%, p=0.03). We found that 0.6% of patients with an ED headache visit had subsequent CVD hospitalization, often at another medical center. ED visits for headache complaints among patients with prior stroke or neurosurgical procedures may be important opportunities for CVD prevention. Documented neurologic examinations were poorer among cases, which may represent an opportunity for ED process improvement.

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs). Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit. We applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for "missed" = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen's kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%). In a large national EHR repository, a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.

Migraine Triggers: An Overview of the Pharmacology, Biochemistry, Atmospherics, and Their Effects on Neural Networks.

We define a migraine trigger to be an endogenous agent or agency such as the menses or an exogenous agent or agency such as red wine or a drop in barometric pressure, and their ability to reduce the threshold of a migraine attack in those predisposed to migraine. This definition excludes agents with idiosyncratic mechanisms that may trigger a migrainous (migraine-like) headache in non-migraineurs such as benign cough headaches or headaches due to altitude-sickness. We also assume as axiomatic that migraine has as its basis the activation of the trigeminovascular pathway (TVP) and the key role of serotonin and the calcitonin gene-related peptide (CGRP). The network activation of the visual/auditory association cortices and the rostrodorsal pons (locus ceruleus and raphe nucleus) are also accepted as key features of activation of the TVP. In addition, we outline the role of the superior salivatory nucleus-sphenopalatine ganglion-greater superficial petrosal nerve (SSN-SPG-GSPN) arc in migraine activation.We also explore how olfactory afferents intermingle with trigeminal nerve collaterals in the glomeruli of the olfactory bulb thus allowing volatile molecules to activate the TVP and induce a migraine. The classification of migraine triggers is complex, as there is a wide panorama of inciting agents, including atmospheric conditions, a wide-ranging variety of foods and beverages, endogenous hormonal influences, synthetic alkaloids and dyes, and volatile molecules (odorants). We will explore the high-frequency migraine-provoking agents in each category. There are exciting and intriguing hypotheses regarding the role of atmospheric chemistry when the barometric pressure drops; the role of hot, dry desert winds and lightning discharges in the generation of cations and the turnover of serotonin in the nervous system. We will explore the effects of a drop in barometric pressure on the vestibular nuclei and the modulation of sympathetically mediated pain. The role of volatile odorants and their activation of the transient receptor potential ankyrin-1 (TRPA-1) receptor will be outlined. We will streamline the highly complex role of estrogen fluctuation in the precipitation of migraine headaches, its pharmacodynamic effects, and the role of the sexually dimorphic nucleus of the preoptic area (SDN-POA) of the hypothalamus. We will also adumbrate the protean effects of alcohol and its congeners and the role of stress and sleep disturbances in the allostatic load model of salience network-pain perception.

Diagnosis and Treatment of Headache in a Pediatric Emergency Department.

The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines. Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine. Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000). Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.

Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization.

The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk. We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods. Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365days (RR: 1.65: 95% CI: 1.18-2.31) and 180days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30days. Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.

Headache in neurological emergency.

Headache represents the second neurological cause of emergency room admittance. The differentiation of the small number of patients with life-threatening headaches from the overwhelming majority with benign primary headaches is an important problem in the emergency department since the misdiagnosis of a secondary headache can have serious consequences, including permanent neurologic deficits and death. The presence of one or more high-risk features (red flags) in patient clinical history or neurological examination warrants an urgent diagnostic workup including blood tests, neuroradiological studies, and lumbar puncture.