Headache Visit Research Articles

Risks associated with opioid prescriptions for headache in the emergency department.

Use of opioids for treatment of headache in the emergency department (ED) is associated with an increased 1-year risk of opioid-related adverse events. To assess the safety and efficacy of opioid prescribing for ED patients with headache. We performed a multicenter observational cohort study using linked administrative data. All patients discharged from an ED in the province of Alberta, Canada with a headache diagnosis between 2010 and 2020 were included. Opioid-treated patients filled opioid prescriptions within 72h of their ED visit, and were matched to untreated controls using propensity scores. The 1-year primary outcome was a composite of long-term prescription opioid use (LTU), opioid-related ED visit or hospitalization, or new opioid agonist therapy (OAT). Secondary outcomes included all-cause acute care utilization and 7-day ED return headache visits. Of 323,932 eligible headache visits, 5.7% received opioids. Opioid-treated patients were comparable to controls on all baseline characteristics. The primary outcome occurred in 8.7% of opioid-treated patients and 5.8% of controls (aOR 1.65 [1.49-1.82]; NNH=29). Opioid-treated patients had higher rates of LTU (7.7% vs. 4.8%), all-cause ED visit (20.8% vs. 19.0%), all-cause hospitalization (16.7% vs. 14.8%), and 7-day revisit (aOR=1.61 [1.49-1.74]; NNH=21) but did not experience more opioid-related ED visits or hospitalizations, or new OAT. Opioid prescription potency and duration were strong predictors of harm. Opioid prescriptions are associated with ED revisits, hospitalizations and LTU in headache patients, without improved efficacy. These findings support the growing notion that opioids are not indicated for ED headache management.

Rural disparities in emergency department utilization for migraine care.

To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Diagnostic Algorithm for Pediatric Headaches: A Clinical Improvement Initiative

BackgroundThe widespread variation in diagnosing primary headache disorders in children and adolescents results in reduced quality and high costs. Defining an algorithm for primary headache diagnoses in children and adolescents is part of a larger initiative to standardize and improve care. The aim of this algorithm was to increase the accuracy of headache diagnosis by formal criteria to more than 80% of patient encounters. MethodsA team of headache specialists, nurse practitioners, nurses, data analysts, and business specialists developed an algorithm based on available scientific evidence. This algorithm was vetted and adapted by the neurology faculty and headache specialists until final consensus was reached. Following three months of testing and validation, the algorithm was disseminated to general pediatric neurology clinics. The following information was gathered: percent of encounters utilizing the algorithm, percentage of encounters with appropriate diagnosis by formal criteria, percentage of encounters with appropriate testing ordered, and average cost per headache visit. ResultsCorrect diagnosis of primary headache by International Classification of Headache Disorders-3 criteria improved from 72% to 90% and appropriate testing improved from 80% to 94%. By the end of analysis, 94% of encounters were correctly implementing the algorithm. A year-long tracking revealed decreased cost of headache evaluation by 6% compared with the year prior. ConclusionsA standardized algorithm improved the diagnostic accuracy in general child neurology clinics. Expanding the algorithm to primary care and pediatric emergency rooms could have a greater impact on headache evaluation and diagnosis; this should result in improved care and outcomes with reduced cost.

Short-term environmental nitrogen dioxide exposure and neurology clinic visits for headaches, a time-series study in Wuhan, China

BackgroundPrevious studies showed the adverse impacts of air pollution on headache attacks in developed countries. However, evidence is limited to the impact of exposure to air pollutants on headache attacks. In this study, we aimed to explore the impact of nitrogen dioxide (NO2) exposure on neurology clinic visits (NCVs) for headache onsets.MethodsRecords of NCVs for headaches, concentrations of ambient NO2, and meteorological variables were collected in Wuhan, China, from January 1st, 2017, to November 30th, 2019. A time-series study was conducted to investigate the short-term effects of NO2 exposure on daily NCVs for headaches. Stratified analyses were also computed according to season, age, and sex, and the exposure–response (E-R) curve was then plotted.ResultsA total of 11,436 records of NCVs for headaches were enrolled in our study during the period. A 10-μg/m3 increase of ambient NO2 corresponded to a 3.64% elevation of daily NCVs for headaches (95%CI: 1.02%, 6.32%, P = 0.006). Moreover, females aged less than 50 years of age were more susceptible compared to males (4.10% vs. 2.97%, P = 0.007). The short-term effects of NO2 exposure on daily NCVs for headaches were stronger in cool seasons than in warm seasons (6.31% vs. 0.79%, P = 0.0009).ConclusionOur findings highlight that short-term exposure to ambient NO2 positively correlated with NCVs for headaches in Wuhan, China, and the adverse effects varied by season, age, and sex.

Racial and Ethnic Disparities in Emergency Department Wait Times for Headache.

Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7min (95%CI: 27.5, 42.0), 46.4min (95%CI: 26.5, 66.4), 37.9min (95%CI: 19.4, 56.3), and 21.0min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

Wildfire smoke exposure and emergency department visits for headache: A case-crossover analysis in California, 2006-2020.

To evaluate the association of short-term exposure to overall fine particulate matter of <2.5 μm (PM2.5 ) and wildfire-specific PM2.5 with emergency department (ED) visits for headache. Studies have reported associations between PM2.5 exposure and headache risk. As climate change drives longer and more intense wildfire seasons, wildfire PM2.5 may contribute to more frequent headaches. Our study included adult Californian members (aged ≥18 years) of a large de-identified commercial and Medicare Advantage claims database from 2006 to 2020. We identified ED visits for primary headache disorders (subtypes: tension-type headache, migraine headache, cluster headache, and "other" primary headache). Claims included member age, sex, and residential zip code. We linked daily overall and wildfire-specific PM2.5 to residential zip code and conducted a time-stratified case-crossover analysis considering 7-day average PM2.5 concentrations, first for primary headache disorders combined, and then by headache subtype. Among 9898 unique individuals we identified 13,623 ED encounters for primary headache disorders. Migraine was the most frequently diagnosed headache (N=5534/13,623 [47.6%]) followed by "other" primary headache (N=6489/13,623 [40.6%]). For all primary headache ED diagnoses, we observed an association of 7-day average wildfire PM2.5 (odds ratio [OR] 1.17, 95% confidence interval [CI] 0.95-1.44 per 10 μg/m3 increase) and by subtype we observed increased odds of ED visits associated with 7-day average wildfire PM2.5 for tension-type headache (OR 1.42, 95% CI 0.91-2.22), "other" primary headache (OR 1.40, 95% CI 0.96-2.05), and cluster headache (OR 1.29, 95% CI 0.71-2.35), although these findings were not statistically significant under traditional null hypothesis testing. Overall PM2.5 was associated with tension-type headache (OR 1.29, 95% CI 1.03-1.62), but not migraine, cluster, or "other" primary headaches. Although imprecise, these results suggest short-term wildfire PM2.5 exposure may be associated with ED visits for headache. Patients, healthcare providers, and systems may need to respond to increased headache-related healthcare needs in the wake of wildfires and on poor air quality days.

Frequency of primary headache disorders and association with body mass index; an ambispective study.

To determine the association of body mass index with various primary headache disorders. The ambispective study was conducted at the Department of Medicine, Shalamar Institute of Health Sciences, Lahore, Pakistan, from January 2020 to March 2021, and comprised data of patients who presented to outpatient departments of Neurology and Medicine with complaint of recurrent or persistent headaches. Body mass index of each subject at the time of latest headache visit was recorded. A control group of 200 individuals was also raised and the body mass index of its subjects was measured. Headache disorders were classified as per International Classification of Headache Disorders-3 beta criteria. Correlation of frequency of different types of primary headaches with body mass index was explored. Data was analysed using SPSS 20. Of the 400 subjects, 200(50%) each were cases and controls. There were 132(33%) males and 268(67%) females. The overall mean age was 37.4 ±14.7 years and mean body mass index was 27.3 ±5.87kg/m2. Migraine was found in 183(46%) subjects compared to tension-type headache 96(24%). Migraine was more common in subjects with high body mass index (p<0.05). Primary headaches constitute a significant health problem. Among various risk factors weight-gain is one that can predispose an individual to increased frequency of migraine.

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.

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.

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.

Headache teleconsultation in the era of COVID-19: Patients' evaluation and future directions.

Background and purposeLiterature regarding headache teleconsultation and patient satisfaction is scarce. The SARS‐CoV‐2 pandemic led to the restructuring of traditional clinical activity by adopting telemedicine. Our objectives were to evaluate patients' satisfaction with headache teleconsultation by telephone during the SARS‐CoV‐2 pandemic and assess patients' preferred model of appointment (face‐to‐face, teleconsultation by telephone, or both).MethodsPatients with a previous diagnosis of primary headache or neuropathies and facial pain disorders, and at least one telephone headache visit during the first wave of COVID‐19, filled out an online questionnaire regarding sociodemographic parameters, satisfaction with teleconsultation, and preferred model of appointment.ResultsWe included 83 patients (valid response rate of 64.3%); most had migraine (83.1%). Regarding teleconsultation, 81.9% considered this model adequate for follow‐up, 88.0% were satisfied with the information provided about the disease/treatment, and 73.5% were satisfied with the medication modification. Ninety percent would agree with a new tele‐evaluation if stable after the pandemic. The mixed model was the preferred medical consultation type for the postpandemic period (43.4%), followed by face‐to‐face visits (33.7%).ConclusionsPatients were satisfied with the headache teleconsultation during the COVID‐19 era. However, an exclusive model of telemedicine does not seem suitable for monitoring all patients. A mixed approach could be integrated into clinical practice after the pandemic to optimize health care.

Sick of news? Television news exposure, collective stressful events and headache related emergency department visits.

Stress is a well-known trigger for primary headache yet its impact is difficult to demonstrate in large epidemiological studies. Israeli national TV news is often referred to as the "tribal fire", as many Israelis watch national news coverage following terror attacks or military operations. We examined the association between exposure to television news and their content with headache related Emergency Department visits. This retrospective cohort study included data on daily Emergency Department visits with a chief complaint of headache in Soroka University Medical Center, during 2002-2012. Data on daily television news viewership ratings were obtained from the Israeli Audience Research Board and its content from Channel 2 headlines, the highest rated TV news program. To estimate the short-term effects of news rating during the evening news on the number of daily headache visits, we applied generalized linear mixed models. 16,693 Emergency Department visits were included in the analysis. An increase in five units of daily rating percentages was associated with increase in Emergency Department visits the following day, relative risk (RR) = 1.032, (95% CI 1.014-1.050). This association increased with the age of the patients; RR = 1.119, (95% CI 1.075-1.65) for older than 60-year-old, RR = 1.044 (95% CI 1.010-1.078) for ages 40-60 and RR = 1.000 (95% CI 0.977-1.023) for younger than 40-year-old. We did not find a specific content associated with ED visit for headache. Higher television news ratings were associated with increased incidence of Emergency Department headache related visits. We assume that especially among older persons, news viewership ratings provide an indirect estimate of collective stress, which acts as a headache trigger for susceptible subjects.

Temporal distribution of emergency room visits in patients with migraine and other headaches

ABSTRACT Background: Headache is a leading reason for presentation to the emergency department (ED) with migraine being the most frequently headache. To ensure the adequate staffing of healthcare providers during peak times of headache visits, we analyzed the temporal distribution of emergency department visits in patients presenting with headache and/or migraine. Research design and methods: The authors conducted an ecological study, including all consecutive visits to the ED for headache. Patients were classified according to the IHS Classification. We analyzed circadian, circaseptan and circannual patterns for number of visits, comparing migraine patients with other headache patients. Results: There were 2132 ED visits for headache, including primary headache in 1367 (64.1%) cases; migraine in 963 (45.2%); secondary headache in 404 (18.9%); and unspecified headache in 366 (17.1%). The circadian pattern showed peaks around 11:00–13:00 and 17:00–19:00, with visits during the night shift 45% less frequent (p < 0.001). The circaseptan pattern showed a peak on Monday-Tuesday and a low point on Sunday (p < 0.007). The circannual pattern peaked in March and decreased in June. Conclusions: ED visits for headache showed specific circadian, circaseptan and circannual variations. No differences were found in these patterns when comparing migraine patients to other headache patients.

Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit.

Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history. We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia. A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n=186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P=0.03), cases were in the ED for longer (6 vs. 5h, P=0.03), and more frequently received neuroimaging (80% vs. 48%; P<0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia. Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.

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.

Factors Associated with Subsequent Cerebral Vascular Disease after Emergency Department Headache Visits: a nested case-control study (984)

Factors Associated with Subsequent Cerebral Vascular Disease after Emergency Department Headache Visits: a nested case-control study (984)

Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study.

BackgroundNeuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches.MethodsThis was a retrospective cohort study using administrative claims data (2001–2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings.Results22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23–0.34%) of the early neuroimaging group and 0.04% (0.02–0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3–19) days versus 72 (39–189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00–3.34%) of the early neuroimaging group and 0.66% (0.58–0.74%) of the referent group (P<0.001).ConclusionsMalignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.

Care of Ebola Survivors and Factors Associated With Clinical Sequelae-Monrovia, Liberia.

The Eternal Love Winning Africa (ELWA) Clinic was the first clinic to provide free, comprehensive care to Ebola virus disease (EVD) survivors in Liberia. The objectives of this analysis were to describe the demographics and symptoms of EVD survivors at ELWA from January 2015 through March 2017 and to identify risk factors for development of sequelae. Patients' demographic and clinical information was collected by chart review in June 2016 and March 2017. Associations with clinical sequelae were analyzed using the chi-square test, t test, and multivariate logistic regression. From January 2015 to March 2017, 329 EVD survivors were evaluated at ELWA. Most survivors experienced myalgia/arthralgia (73%; n = 239) and headache (53%; n = 173). The length of time from Ebola Treatment Unit (ETU) discharge to first clinic visit ranged from 0 to 30 months. Many visits (30%) occurred 24 or more months after ETU discharge. The proportion of visits for headache, weight loss, joint pain, visual problems, insomnia, fatigue, memory loss, decreased libido, depression, and uveitis decreased over time. More men than women had visits for depression; however, these differences were not significant. Symptom prevalence differed in adults and children; significantly more adults experienced myalgia/arthralgia (77% vs 44%), visual problems (41% vs 12%), post-EVD-related musculoskeletal pain (42% vs 15%), and insomnia (17% vs 2%). EVD survivors frequented ELWA for EVD-related symptoms many months after ETU discharge, indicating a long-term need for care. Reported symptoms changed over time, which may reflect eventual resolution of some sequelae.

A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache

ObjectiveHeadaches represent 0.9% to 2.6% of visits to a pediatric emergency department (PED). We noted a trend of increasing visits for headache in our tertiary care PED and sought to further characterize this trend. MethodsWe identified PED visits with International Classification of Disease, Ninth Revision, Clinical Modification diagnoses for headache at 25 hospitals in Pediatric Health Information System between 2003 and 2013. To further characterize demographics and treatment trends over time we used the electronic health record in our emergency department to identify children ages four to 18 between January 2007 and December 2014 with International Classification of Disease, Ninth Revision codes for headache: a random sample of 50 visits per year were chosen for chart review. ResultsPediatric Health Information System visits for headache increased by 166% (18,041 in 2003 and 48,020 in 2013); by comparison, total PED visits increased by 57.6%. The percent admission increased by 300% (2020 admissions in 2003 and 8087 admissions in 2013). At our hospital, headache visits increased 111% from 896 visits in 2007 to 1887 visits in 2014; total PED visits increased 30.2%. The admission percentage for headache increased 187% with 156 admissions in 2007 and 448 in 2014. Management over time differed in the frequency of head computed tomography which decreased 3.7% per year (r = −0.93, 95% CI −0.99, −0.64) from 34% in 2007 to 18% in 2014. ConclusionPediatric emergency department visits for headache are increasing and a growing proportion of these patients are admitted. This finding identifies a potential patient population to target for interventions to improve outpatient management and reduce pediatric emergency department utilization.

Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis.

IntroductionThis study investigated whether a 9.6% decrease in the use of head computed tomography (HCT) for patients presenting to the emergency department (ED) with a chief complaint of headache was followed by an increase in proportions of death or missed intracranial diagnosis during the 22.5-month period following each index ED visit.MethodsWe reviewed the electronic medical records of all patients sampled during a quality improvement effort in which the aforementioned decrease in HCT use had been observed. We reviewed notes from the ED, neurology, neurosurgery, and primary care services, as well as all brain imaging results to determine if death occurred or if an intracranial condition was discovered in the 22.5 months after each index ED visit. An independent, blinded reviewer reviewed each case where an intracranial condition was diagnosed after ED discharge to determine whether the condition was reasonably likely to have been related to the index ED visit’s presentation, thereby representing a missed diagnosis.ResultsOf the 582 separate index ED visits sampled, we observed a total of nine deaths and 10 missed intracranial diagnoses. There was no difference in the proportion of death (p = 0.337) or missed intracranial diagnosis (p = 0.312) observed after a 9.6% reduction in HCT use. Among patients who subsequently had visits for headache or brain imaging, we found that these patients were significantly more likely to have not had a HCT done during the index ED visit (59.2% vs. 49.6% (p = 0.031) and 37.1% vs. 26% (p = 0.006), respectively).ConclusionOur study adds to the compelling evidence that there is opportunity to safely decrease CT imaging for ED patients. To determine the cost effectiveness of such reductions further research is needed to measure what patients and their healthcare providers do after discharge from the ED when unnecessary testing is withheld.