Benign Headache Research Articles

Changes in Demographic and Diagnostic Spectra of Patients with Neurological Symptoms Presenting to an Emergency Department During the COVID-19 Pandemic: A Retrospective Cohort Study.

ObjectiveTo analyse the characteristics of patients with neurological complaints seeking evaluation in an interdisciplinary emergency department (ED) during the rise of the COVID-19 pandemic in Germany.MethodsIn this retrospective study, data on the number of ED presentations due to neurological complaints in weeks 1–15/2020 were collected. In addition, hospital chart data of patients referred for neurological evaluation during weeks 12–15/2020 when the pandemic began impacting on public life in Germany were analysed regarding demographic information, chief complaints, modes of presentation and disposition and ED discharge diagnosis. Both data sets were compared to respective periods from 2017.ResultsDuring the surge of COVID-19, we found a significant decrease of the total number of neurological ED patients by 47.6%. Comparing weeks 12–15 of 2017 and 2020, we found a decrease in the number of patients of <30 years (p<0.001) and an increase of those n ge n70 years (p<0.001). A higher proportion of patients were admitted to escalated care (p=0.03), and fewer patients were discharged against medical advice (p<0.001). In addition, the ratio of less acute diagnoses (eg, benign headaches) declined significantly.ConclusionOur findings suggest that the pandemic has contributed to a – potentially transient – reframing of laypeople’s perception of urgency and necessity for emergency presentation. The establishment and promotion of health-care structures and services like telemedical consultations and the creation of safe ED environments will be essential to enable adequate delivery of care in potential future waves of the pandemic.

I-FiBH trial: intravenous fluids in benign headaches—a randomised, single-blinded clinical trial

BackgroundMany emergency physicians use an intravenous fluid bolus as part of a ‘cocktail’ of therapies for patients with headache, but it is unclear if this is beneficial. The objective of...

Treatment of Headache in the Emergency Department: Haloperidol in the Acute Setting (THE-HA Study): A Randomized Clinical Trial.

Headache is a common complaint of emergency department (ED) patients and current treatment varies with significant limitations. Our aim was to evaluate the efficacy and safety of 2.5mg i.v. haloperidol in the treatment of severe benign headache in the ED. A randomized, double-blind, placebo-controlled trial was performed in the ED of a single high-volume teaching hospital. Convenience sampling identified 287 eligible patients 13 to 55years old with benign headache. One hundred and eighteen patients were enrolled to receive either 2.5mg of haloperidol i.v. or placebo. The primary outcome measure was pain reduction at 60min. Patients were evaluated for adverse events and follow-up was conducted after discharge. QT measurement was performed at baseline and discharge. Fifty-eight patients received haloperidol and 60 patients received placebo. Patients in the haloperidol group reported an average 4.77-unit reduction in visual analogue scale score at 60min compared to a 1.87-unit reduction in the control group. Thirty-four patients (58.6%) in the haloperidol group had complete resolution of their headache. Treatment with rescue ketorolac was required in 78.3% of the control group and 31% of the haloperidol group. Adverse events were uncommon, benign, and easily treated. No patients in the haloperidol group were found to have QT lengthening. This study suggests that 2.5mg i.v. haloperidol is a rapid and effective treatment for acute, severe, benign headache in ED patients aged 18 to 55years. Further study is warranted to confirm these results in adolescents. ClinicalTrials.gov Identifier NCT02747511.

Abstract WMP91: Head CT at Emergency Department Treat-and-Release Visit for Headache is Associated With Increased Risk of Subsequent Hospitalization for Cerebrovascular Disease

Background: Headache is a common presenting symptom among patients with misdiagnosed cerebrovascular (CVD) disease. Recent studies report that the occurrence of a head CT (HCT) during emergency department (ED) visit for non-specific neurological symptoms, such as vertigo, is associated with increased risk of stroke after ED discharge. We sought to evaluate whether the occurrence of HCT at ED visit for headache is associated with increased CVD risk. Hypothesis: Patients with headache complaints who have a HCT performed in the ED (exposed) are more likely to have a CVD admission within 365 days of ED discharge than those who do not receive a HCT (unexposed). Methods: We conducted a retrospective study of consecutive adult patients with headache complaints discharged to home (treat-and-release visit) from all four of the EDs affiliated with a single academic institution. Patients with headache complaints were defined as those with primary ICD-9/10-CM discharge diagnosis of benign headache; patients were included in our study at their first ED treat-and-release visit from 2013 to 2018. Subsequent CVD hospitalizations were identified using ICD-9/10-CM inpatient discharge codes and confirmed via chart review. We matched exposed to unexposed patients in a one-to-one fashion using propensity score methods. Standard descriptive statistics and relative risk (RR) with 95% CIs are reported. Results: Among 28,121 patients with an ED treat-and-release visit for headache complaints, 45.6% (n=12,812) underwent HCT during ED visit. A total of 0.4% (n=112) patients had a subsequent CVD admission within 365 days of ED visit. Using propensity score matching, 80.3% (n=10,295) of patients with HCT (exposed) were able to be matched. In the matched sample, exposed patients had a nearly two-fold increased relative risk of CVD at 365 days (RR: 1.83; 95% CI: 1.12-3.01). In secondary analysis, CVD risk at 180 days was also higher in exposed (RR: 2.06; 95% CI: 1.13-3.74). Conclusion: Having a HCT performed at index ED treat-and-release visit among those with headache complaints establishes a clinically meaningful risk gradient for subsequent CVD hospitalization. Some ED patients given a headache diagnosis may have been misdiagnosed at index visit.

Out-of-hospital assessment and treatment of adults with atraumatic headache.

ObjectiveLittle is known about the presentation or management of patients with headache in the out‐of‐hospital setting. Our primary objective is to describe the out‐of‐hospital assessment and treatment of adults with benign headache. We also describe meaningful pain reduction stratified by commonly administered medications.MethodsThis retrospective evaluation was conducted using data from a large national cohort. We included all 911 responses by paramedics for patients 18 and older with headache. We excluded patients with trauma, fever, suspected alcohol/drug use, or who received medications suggestive of an alternate condition. We presented our findings with descriptive statistics.ResultsOf the 5,977,612 emergency responses, 1.1% (66,235) had a provider‐documented primary impression of headache or migraine and 52.5% (34,763) met inclusion criteria. An initial pain score was recorded for 73.5% (25,544) of patients, and 58.5% (14,948) of these patients had multiple pain scores documented. Of the patients with multiple pain scores documented, 53.8% (8037) of patients had an initial pain score >5. Of these, 7.1% (573) were administered any medication. Among patients receiving a single medication, Fentanyl was the most commonly administered (32.1%, 126). As a group, opioids were the most commonly administered class of drugs (38.9%, 153) and were associated with the largest proportion of clinically significant pain reduction (69.3%, 106). Dopamine antagonists were given least frequently (9.9%, 39) but had the second largest proportion of pain reduction (43.6%, 17).ConclusionOut‐of‐hospital pain scores were documented infrequently and less than one in five patients with initial pain scores >5 received medication. Additionally, adherence to evidence‐based guidelines was infrequent.

Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review.

Non-traumatic headaches comprise up to 4% of all emergency department (ED) visits. Current practice is moving toward multimodal analgesia regimens that limit narcotic use. The objective of this systematic review is to address the following research question: In patients with non-traumatic headaches (Population), does administration of intravenous magnesium sulfate (Intervention) compared to placebo, corticosteroids, dopamine antagonists, ergot alkaloids, non-steroidal anti-inflammatory drugs (NSAIDs), triptans, or usual care result in better pain control, lower rate of recurrence at 24hours, lower requirements for rescue analgesia, and less adverse medication effects (Outcomes)? Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) patients age ≥18 years, (3) non-traumatic headache, (4) patients treated in ED or an outpatient acute care treatment center, and (5) magnesium sulfate administered intravenously (IV). Eligible comparison groups included: placebo, conventional therapy, dopamine antagonist, NSAID, corticosteroid, ergot alkaloid, or triptans. Out of 4018 identified references, 7 RCTs (545 participants) that treated migraine headaches (n=6) and benign non-traumatic headaches (n=1) met inclusion criteria. Pain intensity was improved with magnesium sulfate vs comparators at 60-120 minutes, but not at earlier time points. Result for the endpoint of pain reduction by 50% were conflicting as 3 studies reported that headache was improved, unchanged, and less with magnesium sulfate. Complete pain relief was improved with magnesium sulfate in 1 study, and in the migraine with aura (MA) subgroup in another. The need for rescue analgesia at any point was improved with magnesium sulfate in 1 study, and in the MA subgroup in another. Twenty-four-hour headache recurrence was improved with magnesium sulfate in 1 study, but unchanged in a second. The intended meta-analysis was not performed due to the clinical heterogeneity among studies. While we cannot draw a firm conclusion on the efficacy or benefit of intravenous magnesium sulfate in the treatment of acute non-traumatic headaches, the existing evidence indicates potential benefits in pain control beyond 1hour, aura duration, and need for rescue analgesia.

Management of Childhood Headache in the Emergency Department. Review of the Literature.

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

P075: Emergency physicians’ self-reported management of benign headache in Alberta emergency departments

Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.

P077: Piloting imaging-focused knowledge dissemination tools in Alberta emergency departments

Introduction: Variation in image ordering exists across Alberta emergency departments (EDs). Evidence-based, pocket-sized knowledge dissemination tools were developed for two conditions (acute asthma [AA] and benign headache [BHA]) for which imaging (chest x-ray [CXR] and computed tomography [CT], respectively) has limited utility. This study explored tool acceptability among ED patients and emergency physicians (EPs). Methods: Tool feedback was provided by EPs, via online survey, and adult patients with AA and BHA via in-person survey. EPs qualitative interviews further explored communication tools. Preliminary descriptive analyses of survey responses and content analysis of interview data were conducted. Results: Overall, 55 EPs (55/192; 29%) and 38 consecutive patients participated in the AA study; 73 EPs (73/192; 38%) and 160 patients participated in the BHA study. In both studies, approximately 50% of EPs felt comfortable using the tool; however, they suggested including radiation risk details and imaging indications and removing references to imaging variation and health system cost. In the BHA study, EPs opposed the four Choosing Wisely® campaign questions fearing they would increase imaging expectations. In both conditions, most patients ( &amp;gt;90%) understood the content and 68% felt the information applied to them. Less than half (AA:45%; BHA: 38%) agreed that they now knew more about when a patient should have imaging workup done. Following tool review, 71% of AA and 50% of BHA patients stated they would discuss their imaging needs with their ED care provider today or during a future presentation. Both patient groups suggested including: additional imaging details (i.e., indications, risk, clinical utility), removing imaging overuse references, and including instructions that encourage patients to ask their EP questions. EP interviews (n = 12) identified preferences for personalized and interactive tools. Tensions were perceived around ED time pressure as well as remuneration schemes that fail to prioritize patient conversation. Tool centralization, easy access, and connection with outpatient support were also key themes. Conclusion: Both patients and EPs provided valuable information on how to improve ED knowledge dissemination tools, using two chronic conditions to demonstrate how these changes would improve tool utility. Implementing these recommendations, and considering preferences of EPs and patients, may improve future tool uptake and impact.

P149: Benign headache management in Alberta emergency departments: a chart review study to explore gaps in practice

Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.

Evaluation and Management of the Emergency Department Headache.

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache-which may be broadly categorized into structural, infectious, and vascular causes-is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

Headache after Delivery, a Misleading Presentation of Sheehan's Syndrome: A Case Report

Post dural puncture is one of the most common causes of postpartum headache. Other causes are benign primary headache disorders (migraine, tension-type headache) and secondary headache disorders such as stroke, ischaemia or pituitary apoplexy and venous sinus thrombosis. Headache in the new mother after delivery, mandates a differential diagnosis because it is not appropriate to focus only on the most common diseases, such as post dural puncture headache. In this report we discuss a case of postpartum headache with delayed cause diagnosis in complicated labour and delivery.

Relationship between migraine and hypertensive disorders of pregnancy

Aim: Preeclampsia is a pregnancy-specific syndrome associated with vascular spasm and endothelium dysfunction that leads to reduced organ blood flow. Migraine is a syndrome of benign recurrent headaches, nausea, vomiting, or other signs of neurologic dysfunction. Some studies have shown that women who have a history of migraines during pregnancy are at high risk of preeclampsia. The aim of this was determine the relation between migraine and hypertensive disorders of pregnancy. Material and Methods: In this case- control study, cases consisted of 100 women with preeclampsia, and controls were 100 normotensive women. All women were hospitalized in Ardabil city hospital and all of them were evaluated for any history of migraine. The two groups were matched for confounding factors. The data were collected by questionnaire including demographic, medical, obstetrics, and migraine assessment sections. Data were analyzed by statistical methods using SPSS version 19.Results: The mean age of women in study group was 28.12±6.50 and in control group was 25.2±5.75. Majority of persons in the study, were in age group16 to 35 years old and their education levels were high school graduates and they were housewives. The mean of BMI was 24.8. Of people, 11% were suffering from migraine. The history of migraine in the study group was 16% and in the control group was 6% and the difference was significant between two groups (p=0.001). History of migraine headaches in patients with hypertensive disorders was 2.65 times more than women in control group. Conclusion: Results showed that migraine headaches to be associated with gestational hypertension and history of any migraine could be as a risk factor for PE /gestational hypertension (GH) in future. Keywords: Gestational hypertension; migraine; preeclampsia.

Retinal metastasis of carcinoid presenting with headache: a case representation

Background: Headache is one of the most common somatic symptoms in patients who search emergency department (ER). Diagnosing and treating the most common headache disorders are not so difficult. Thus, recognizing some types of headaches, either primary or secondary, can be challenging. Case Presentation: We present an interesting and challenging case of a patient who referred to the ER because of a benign headache and proved to suffer from a metastatic tumor of the retina due to lung carcinoid. Conclusion: Unusual headache syndromes do not appear to be as rare in clinical practice as has been generally believed. To our knowledge, this is the first time to report a metastatic carcinoid of retina presenting with isolated headache and redness of sclera as a primary symptoms. Appropriate identification of the secondary cause of a headache is the key to successful treatment.

The effect of peer influence on the use of CT by emergency physicians for patients with headaches

BackgroundIt is challenging for emergency physicians (EPs) to distinguish between patients with life-threatening and benign headaches. We examined the effect of peer influence on computed tomography use by EPs for patients with headache and evaluated the peer influence effect in EPs with different levels of risk tolerance. MethodsWe conducted a before- and after-retrospective case review, and administered the Risk-Taking subscale of the Jackson Personality Index to attending physicians. Each EP computed tomography (CT) use rate, patient number, and CT use, were e-mailed every two months to enhance EP team norm and establish a trend in behavior. ResultsOf the 665 (before intervention) and 669 (after intervention) patients with headache, 206 (31%) and 171 (25.6%) underwent brain CT scans, respectively. Decreased use of CT examination was found in the post-intervention group (OR = 0.758, 95% CI: 0.593–0.967), especially for most risk-tolerant physicians (OR = 0.530, 95% CI: 0.311–0.889). There was prolonged ED length of stay (LOS) in the pre-intervention group (OR = 51.52, 95% CI: 26.998–76.050). ConclusionsWe observed that peer influence is an effective way to improve CT use rate and emergency department LOS for patients with isolated headache, especially for most risk-tolerant physicians. These findings could enhance the development of appropriate guidelines to assist ED physicians' CT use.

A review of 50 cases of bath-related headache: clinical features and possible diagnostic criteria.

To describe clinical features and possible diagnostic criteria of the 50 bath-related headache (BRH) cases that have been published in the literature to date. Based on a literature search in the major medical databases, we analyzed all case reports or case series on BRH that were published between 2000 and 2017. We describe 48 women and two men diagnosed with BRH. Of these 50 patients, 90% were from Asian countries. The average age was 49.3 years. There was an association of BRH with migraine (28%), tension-type headache (12%) and cold stimulus headache (4%). Headache was bilaterally localized, had an explosive or pulsating quality and a severe intensity. The pain lasted from five minutes to four days. Associated manifestations were nausea, vomiting, photophobia or phonophobia. There was a good therapeutic response with nimodipine and when avoiding a hot bath. Bath-related headache is a benign headache that is not associated with a structural lesion.

Diversity of Hypoxis species used in ethnomedicine in Tanzania

The corms of different Hypoxis species (Hypoxidaceae) are used for the treatment and management of a variety of human ailments and disorders in African traditional medicine. However, the used corms are morphologically similar and it is not known whether this has resulted in different species being harvested, prescribed and sold as the same species. Ethnomedicinal information regarding its use in Tanzania is scanty and the available ethnobotanical information about the plants is mostly from various studies done outside Tanzania. The objective of the study was to document the diverse uses of Hypoxis in Tanzania and study what species are used and whether preferences exist for specific species. Focus group discussions and in depth interviews with informants were done in 15 regions of Tanzania to document local uses of Hypoxis species and collect vouchers for identification. Traditional practitioners use Hypoxis to manage a variety of human illness in Tanzania, and appear to use different species indiscriminately for medicine, socio-cultural applications and for food. Medicinal uses include treatment of benign prostate hypertrophy, cancer, diabetes, gout, headache, HIV/AIDS, infertility, ringworms, stomachache, and urinary tract infections. In Tanzania, different Hypoxis species are used indiscriminately for a range of socio-cultural and medicinal purposes. The reported medicinal uses could aid testing and evaluation of traditional herbal medicine and more research is needed to test their pharmacological effects.

Understanding Spreading Depression from Headache to Sudden Unexpected Death.

Spreading depression (SD) is a neurophysiological phenomenon characterized by abrupt changes in intracellular ion gradients and sustained depolarization of neurons. It leads to loss of electrical activity, changes in the synaptic architecture, and an altered vascular response. Although SD is often described as a unique phenomenon with homogeneous characteristics, it may be strongly affected by the particular triggering event and by genetic background. Furthermore, SD may contribute differently to the pathogenesis of widely heterogeneous clinical conditions. Indeed, clinical disorders related to SD vary in their presentation and severity, ranging from benign headache conditions (migraine syndromes) to severely disabling events, such as cerebral ischemia, or even death in people with epilepsy. Although the characteristics and mechanisms of SD have been dissected using a variety of approaches, ranging from cells to human models, this phenomenon remains only partially understood because of its complexity and the difficulty of obtaining direct experimental data. Currently, clinical monitoring of SD is limited to patients who require neurosurgical interventions and the placement of subdural electrode strips. Significantly, SD events recorded in humans display electrophysiological features that are essentially the same as those observed in animal models. Further research using existing and new experimental models of SD may allow a better understanding of its core mechanisms, and of their differences in different clinical conditions, fostering opportunities to identify and develop targeted therapies for SD-related disorders and their worst consequences.

Benign Headache Management in the Emergency Department

BackgroundHeadache is a common complaint managed in the emergency department (ED), with emergency physicians focusing on evaluation for life-threatening conditions while treating pain and nausea. ObjectiveThis review evaluates the treatment of benign, primary headaches in the ED, with recommendations provided based on the literature. DiscussionHeadaches are a major cause of disability in the United States and a common condition managed in the ED. The primary objectives of emergency evaluation of these patients include evaluation for a life-threatening, secondary cause of headache, with treatment of primary headaches. Close evaluation for a secondary cause of headache include consideration of red flags and focused neurologic examination. The diagnosis of primary headaches is clinical. Literature has evaluated medication efficacy in headache treatment, with antidopaminergic medications demonstrating high rates of efficacy when used in combination with nonsteroidal inflammatory drugs or acetaminophen. Dexamethasone can be used for the reduction of headache recurrence. If dehydration is present, intravenous fluids should be provided. Diphenhydramine is not recommended for analgesia but may reduce akathisia associated with prochlorperazine. Ketamine, propofol, and nerve blocks demonstrate promise. Triptan agents are also efficacious, provided absence of contraindications. Most patients are appropriate for discharge with pain improvement. ConclusionsA variety of medications is available for the treatment of primary headaches in the ED. Antidopaminergic agents demonstrate the highest efficacy and should be provided with acetaminophen and nonsteroidal inflammatory drugs. Dexamethasone may reduce headache recurrence. Other treatments include ketamine, propofol, and nerve blocks.

Abstract 139: Low Rate of Probable Misdiagnosis of Cerebral Vein Thrombosis in a Multi-State Cohort

Introduction: Cerebral vein thrombosis (CVT) is a cerebrovascular disease that affects young adults, is difficult to diagnose, and can result in significant disability and death. Studies aimed to evaluate rates of CVT misdiagnosis are limited. Hypothesis: Misdiagnosis of CVT in the emergency department (ED) would be common and associated with adverse outcomes. Methods: We performed a retrospective cohort study using ED visits and hospitalizations in California, New York and Florida from 2005 to 2013. We identified patients with CVT using previously validated International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM) codes. Primary outcome was a probable misdiagnosis of CVT, defined as an ED visit for benign headache or seizure within 14 days of CVT. In secondary analyses, we assessed whether a probable misdiagnosis of CVT was associated with an increased risk of intracerebral hemorrhage or inpatient mortality. Descriptive statistics was used to calculate crude rates and multivariable logistic regression to compare rates of adverse outcomes. A confirmatory cohort analysis of CVT patients from two tertiary care centers was conducted via detailed chart review. Results: We identified 5,966 patients with CVT. Mean age was 44.2 ± 18.4 years and 71.7% were women. A total of 216 patients (3.6%; 95% CI, 3.1-4.1%) had a probable misdiagnosis of CVT. Misdiagnosed patients were younger and less likely to have congestive heart failure, atrial fibrillation, cancer, or trauma, but more likely to have a hypercoagulable state. No pregnant patients with CVT (n=758, 12.5%) had a probable misdiagnosis. In confirmatory cohorts, probable CVT misdiagnosis occurred in 8.1% (6 of 74) and 2.6% (2 of 76) of patients. Misdiagnosis of CVT was not associated with an increased risk of death (OR, 0.1; 95% CI, 0.0-1.1), intracerebral hemorrhage (OR, 1.0; 95% CI, 0.6-1.6), unfavorable discharge disposition (OR, 0.9; 95% CI, 0.6-1.3), but was associated with an increased length of stay (OR 1.7; 95% CI, 1.2-2.3). Conclusion: In a large, heterogeneous group of patients, a probable misdiagnosis of CVT occurred in 1 out of 30 patients. No misdiagnosis occurred in a pregnant patient and misdiagnosis was not associated with adverse clinical outcomes.