Headaches After Concussion in US Soldiers Returning From Iraq or Afghanistan

(Headache 2010;50:1262‐1272) Objectives.— To determine the prevalence, characteristics, impact, and treatment patterns of headaches after concussion in US Army soldiers returning from a deployment to Iraq or Afghanistan. Methods.— A cross‐sectional study was conducted with a cohort of soldiers undergoing postdeployment evaluation during a 5‐month period at the Madigan Traumatic Brain Injury Program at Ft. Lewis, WA. All soldiers screening positive for a deployment‐related concussion were given a 13‐item headache questionnaire. Results.— A total of 1033 (19.6%) of 5270 returning soldiers met criteria for a deployment‐related concussion. Among those with a concussion, 957 (97.8%) reported having headaches during the final 3 months of deployment. Posttraumatic headaches, defined as headaches beginning within 1 week after a concussion, were present in 361 (37%) soldiers. In total, 58% of posttraumatic headaches were classified as migraine. Posttraumatic headaches had a higher attack frequency than nontraumatic headaches, averaging 10 days per month. Chronic daily headache was present in 27% of soldiers with posttraumatic headache compared with 14% of soldiers with nontraumatic headache. Posttraumatic headaches interfered with duty performance in 37% of cases and caused more sick call visits compared with nontraumatic headache. In total, 78% of soldiers with posttraumatic headache used abortive medications, predominantly over‐the‐counter analgesics, and most perceived medication as effective. Conclusions.— More than 1 in 3 returning military troops who have sustained a deployment‐related concussion have headaches that meet criteria for posttraumatic headache. Migraine is the predominant headache phenotype precipitated by a concussion during military deployment. Compared with headaches not directly attributable to head trauma, posttraumatic headaches are associated with a higher frequency of headache attacks and an increased prevalence of chronic daily headache.     

One or Several Types of Triptan Overuse Headaches?

Background.— Whereas the clinical features of pure triptan overuse headache (TOH) are well known, there are insufficient data regarding the semiological pattern of headaches when triptan overuse is associated with other types of medication overuse.
Objective.— To investigate and compare the clinical characteristics of patients with pure TOH and those with medication overuse headaches associating triptan and other medication overuses (combined TOH).
Methods.— This cross-sectional, observational study was conducted in 7 tertiary-care headache centers participating in the French Observatory of Migraine and Headaches. From 2004 to 2006, data from 163 patients with TOH were collected in face-to-face structured interviews (according to the International Classification of Headache Disorders, 2nd edition criteria).
Results.— Eighty-two patients fulfilled criteria for pure TOH (pTOH patients) and 81 for combined TOH (cTOH) patients. Continuous headaches were reported in 76% of cTOH patients compared with 32% of pTOH patients. Significantly more frequent and severe headaches and more intense phono-/photophobia between attacks were noted in cTOH patients. More cTOH than pTOH patients reported a history of tension-type headaches and a long-standing history of chronic headaches. Finally, compared with pTOH patients, cTOH patients were characterized by stronger dependence on acute treatments of headaches according to the DSM-IV criteria.
Conclusions.— Combined therapy with analgesics and/or the total number of drug units taken per day may cause a shift from a pattern of clear-cut headache attacks in patients with pTOH toward more severe clinical presentation in patients with cTOH. These patients should receive more intensive prophylactic therapy and specific behavioral management.     

Prevalence and Burden of Headache and Migraine in Germany

Objective.— To determine prevalence and burden of headache and migraine in the general population in Germany including patterns of healthcare and medication use.
Methods.— Telephone interviews were conducted on a representative sample of the general population in Germany aged ≥18 years (n = 7341). Migraine was diagnosed according to the International Headache Society criteria.
Results.— One-year prevalence was: headache 60.2%, migraine 10.6%, nonmigrainous severe headache 24.7% (women 66.6%, 15.6%, and 27.1%; men 53.0%, 5.3%, and 22.2%). Approximately 60% of headache sufferers reported severe headaches, 30% of which were migrainous. Migraineurs reported more often frequent headaches, disability, use of analgesics, and medical consultation than individuals with nonmigrainous severe headaches. Only 42% of migraineurs had consulted a physician and the majority relied exclusively on over-the-counter medication.
Conclusion.— Migraine accounts for a great part of the healthcare impact of headaches in Germany. However, the majority of migraineurs do not seek medical care and may not be optimally treated.     

Ambient air pollution and daily emergency department visits for headache in Ottawa, Canada

Background.— No extensive studies exist on the relation between ambient air pollution and health outcomes such as migraine or headache. From other side, existing publications indicated that air pollutants can trigger migraine or headache.
Objective.— To examine associations between emergency department (ED) visits for headache and environmental conditions: ambient air pollution concentrations adjusted for weather factors (atmospheric pressure, temperature, and relative humidity).
Design and Methods.— This is a time-series study of 8012 ED visits for headache (International Classification for Diseases ninth revision: 784) recorded at an Ottawa hospital between 1992 and 2000. The generalized linear mixed models technique is used to model relation between daily counts of ED visits for headache and ambient air pollutants (gases: sulphur dioxide [SO₂], nitrogen dioxide [NO₂], carbon monoxide [CO]). The counts of visits for all patients, male and female patients, are analyzed separately.
Results.— The percentage increase in daily ED visits for headache was 4.2% (95% CI: 0.2, 6.4) and 4.9% (95% CI: 1.2, 8.8) for 1-day and 2-day lagged exposure to SO₂ for an increase in the interquartile range (IQR, IQR = 3.9 ppb). The positive statistically significant associations were also observed for exposure to NO₂ and CO for all and male ED visits for headache.
Conclusions.— Presented findings provide support for the hypothesis that ED visits for headache are related to ambient air pollution.     

Benign Headache Management in the Emergency Department

Background

Headache 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.

Steroids for Migraine Headaches: A Randomized Double-Blind, Two-Armed, Placebo-Controlled Trial

Background: Recurrence of migraine headache after treatment in the emergency department (ED) is common. Conflicting evidence exists regarding the utility of steroids in preventing migraine headache recurrence at 24–48 h. Objective: To determine if steroids decrease the headache recurrence in patients treated for migraine headaches in the ED. Methods: Double-blind placebo-controlled, two-tailed randomized trial. Patients aged >17 years with a moderately severe migraine headache diagnosed by treating Emergency Physician were approached for participation. Enrollees received either dexamethasone (10 mg i.v.) if intravenous access was utilized or prednisone (40 mg by mouth × 2 days) if no intravenous access was obtained. Each medication was matched with an identical-appearing placebo. Patients were contacted 24–72 h after the ED visit to assess headache recurrence. Results: A total of 181 patients were enrolled. Eight were lost to follow-up, 6 in the dexamethasone group and 2 in the prednisone arm. Participants had a mean age of 37 years (±10 years), with 86% female. Eighty-six percent met the International Headache Society Criteria for migraine headache. Of the 173 patients with completed follow-up, 20/91 (22%) (95% confidence interval [CI] 13.5–30.5) in the steroid arm and 26/82 (32%) (95% CI 21.9–42.1) in the placebo arm had recurrent headaches (p = 0.21). Conclusion: We did not find a statistically significant decrease in headache recurrence in patients treated with steroids for migraine headaches.     

Prevalence and impact of migraine among US Army soldiers deployed in support of Operation Iraqi Freedom

Objectives.— To assess the prevalence and impact of migraine headaches in US Army soldiers deployed in support of Operation Iraqi Freedom.
Methods.— A brigade of US Army soldiers stationed at Ft. Lewis, Washingtion was given a self-administered headache questionnaire within 10 days of return from a 1-year combat tour in Iraq. Soldiers who screened positive for migraine were surveyed again by phone 3 months after return from Iraq.
Results.— In total, 19% of soldiers screened positive for migraine and 17% for possible migraine. Soldiers with a positive migraine screen had a mean of 3.1 headache days per month, a mean headache duration of 5.2 hours, and a mean of 2.4 impaired duty days per month due to headache. Soldiers with migraine made a total of 490 sick call visits for headache over a 3-month period compared with 90 sick call visits among those with possible migraine. In all, 75% of the soldiers with migraine used over-the-counter analgesics and only 4% used triptans. Soldiers with migraine contacted 3 months after returning from Iraq had a mean of 5.3 headache days per month and 36% had a Migraine Disability Assessment Scale grade of 3 or 4.
Conclusions.— Migraine headaches are common in deployed US Army soldiers exceeding the expected prevalence. These headaches result in impaired duty performance and are a frequent cause of sick call visits. Migraine headaches tend to persist after deployment in many soldiers.     

Headache in an Italian pediatric emergency department

The objective of this study was to assess epidemiology, diagnostic work-up, treatment and follow-up of children presenting to emergency department (ED) with headache. Records of visits for non-traumatic headache to the ED of a pediatric hospital over a period of 12 months were retrospectively reviewed. Headache center charts were analyzed one year after. Five-hundred and fifty patients (1% of all ED visits) were included. Spectrum of diagnoses was: primary headache (56.7%), with 9.6% of migraine; secondary headache (42%); unclassified headache (1.3%). Viral illnesses accounted for 90.5% of secondary headaches. A serious disorder was found in 4% of patients. Forty-four patients (8%) underwent neuroimaging studies, with 25% of abnormal findings. Only 223 patients (40.5%) received pharmacological treatment. On discharge, 212 patients (38.5%) were referred to headache center and 114 (20.7% of all patients) attended it. ED diagnosis was confirmed in 74.6% of cases. Most of ED repeated visits (82.6%) occurred in patients not referred to headache center at discharge from first ED visit. The most frequent diagnosis was primary headache; viral illnesses represented the majority of secondary headaches. Underlying serious disorders were associated with neurological signs, limiting the need of diagnostic investigations. Well structured prospective studies are needed to evaluate appropriate diagnostic tools, as well as correct therapeutic approach of pediatric headache in emergency. Collaboration with headache center might limit repeated visits and provide a correct diagnostic definition.     

Do patients with recurrent headaches attempt abortive therapy before their emergency department visit?

Headache is one of the most frequent symptoms prompting an emergency department (ED) visit. For many patients this is an exacerbation of a recurrent or chronic headache pattern. Our objective in this study was to determine if ED patients with recurrent headaches attempt abortive analgesics before seeking ED care. Patients with five or greater similar headache episodes presenting to the ED with the chief complaint of headache were included. There were 150 patients enrolled into the study group. Fourteen percent (95% confidence interval 1-41) of patients did not attempt abortive medication before an ED visit. Males were significantly less likely to utilize pain medication than females before their ED visit (69% vs. 91%; p = 0.003). Of those patients previously seen by a neurologist, 5% did not attempt analgesia before ED arrival, compared to 22% of those who did see a neurologist (p = 0.004). A small, but significant percentage of patients with recurrent headaches do not attempt abortive analgesic therapy before ED encounter. In particular, males and those patients not previously evaluated by a neurologist were significantly less likely to utilize such medications. Further education and selective neurology referral by practitioners may reduce ED utilization in this subset of patients.     

The Presentation of Headache in Neuro-Behçet's Disease: A Case-Series

Introduction.— Behçet's disease (BD) is a chronic, relapsing, multisystemic, inflammatory disorder with unknown etiology. Neurological involvement is observed in about 5% of the patients with BD and headache is a frequently reported symptom with or without neurological involvement. In this case-series, we aim to demonstrate the secondary headaches associated with neuro-Behçet's disease in consecutive BD patients who had been referred for neurologic evaluation.
Methods.— The case-series included 17 patients (11 males [65%]), mean age 41 ± 11.4, who met the criteria for BD established by the International Study Group for BD and developed headache during the disease course.
Results.— Seventeen BD patients were identified, the neurologic presentations included in parenchymal involvement 12 (70%), extraparenchymal involvement/venous thrombosis in 5 (30%), seizure disorder in 2 (12%), and psychiatric problems/depression or anxiety in 5 (30%) patients, respectively. The characteristics of the headache according to the patients' reports included subacute, moderate to severe headache with unilateral localization and throbbing quality accompanied by nausea, vomiting, and aggravation upon awakening.
Conclusion.— Because neurological involvement is one of the most devastating aspects of BD, the need to treat neurological involvement as early as possible, the possible role of headache onset as an early indicator for neurological involvement in this relatively uncommon disease should be kept in mind.     

Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.     

A rare cause of headache: cerebral venous sinus thrombosis due to hyperthyroidism

Headache represents up to 4% of all emergency department (ED) visits. Emergency physicians generally are concerned with identifying those patients whose headaches are caused by life-threatening conditions. Cerebral venous sinus thrombosis may be difficult to diagnose clinically because of its various and nonspecific manifestations. The most frequent but least specific symptom of sinus thrombosis is severe headache, which is present in more than 90% of adult patients. In the case report we present, a patient had severe headache and was diagnosed until third ED visit at different hospitals. He had one of the most unusual causes of headache, that is, cerebral venous sinus thrombosis due to hyperthyroidism.     

Disability associated with headaches occurring inside and outside the menstrual period in those with migraine: a general practice study

Objectives.—This study investigated the disability of females who have migraine and other headache attacks occurring during and outside the menstrual period.
Methods.—One thousand four hundred and thirty-four of 3470 female patients (41.3%) aged 14 to 50 years registered at a UK general practice completed two questionnaires. The first questionnaire assessed the prevalence of headache, depression, and bodily pain in the total population. The second questionnaire assessed the disability of all headaches over a 2-month period (to capture a complete menstrual cycle) for patients reporting migraine who were still menstruating. Disability was assessed as the time lost and time spent at less than 50% productivity in normal activities due to headache, and analyzed as rank sums using the Mann-Whitney U -test.
Results.—The first part of the study showed that the prevalence of headache (66.1%), depression (55.4%), and bodily pain (40.6%) were high in this population of women. Thirty migraine patients who were still menstruating reported 89 migraine and 114 nonmigraine headache episodes in the second part of the study. For migraine, the rank order of time at less than 50% productivity was greater for attacks taking place inside the menstrual period than for those occurring outside the menstrual period. The comparison was significant for time at less than 50% productivity ( P = .01). For nonmigraine headaches, the rank order of time lost was greater for attacks taking place outside the menstrual period than for those occurring inside the menstrual period. The comparison was not significant for time lost ( P = .06).
Conclusions.—For those with migraine, migraine attacks that took place during the menstrual period tended to be slightly more disabling than those taking place outside the menstrual period, but the opposite was true for nonmigraine headache.     

Headache patients in the emergency department of a Greek tertiary care hospital

The aim of this study was to record the demographic and epidemiological data on adult patients with headache who attend the emergency department (ED) and the diagnoses that made by the neurologists in the ED of a tertiary care hospital in metropolitan Thessaloniki (Greece). In an open prospective study, demographic and epidemiological data were collected on all patients who reported headache (as chief complaint or not) and presented to the ED of Papageorgiou Hospital between August 2007 and July 2008. Headache patients accounted for 1.3% of all ED patients and for 15.5% of patients primarily referred to the ED neurologist. Tension type headache was the most frequent diagnosis, followed by secondary headaches and migraine. The large number of patients without final ED diagnosis and ward admission for further evaluation sheds a light on the immense workload of Greek ED physicians. Furthermore, we found evidence for the misuse of Emergency Medical Services by chronic headache patients. These findings indicate shortcomings in the pre-hospital (primary care) management of headache patients in the Greek National Health System to an extent unreported so far.     

Does Early Migraine Treatment Shorten Time to Headache Peak and Reduce Its Severity?

Objective.— To explore whether early treatment would shorten the duration of headache from headache onset to its peak and reduce headache severity at peak.
Background.— Prior clinical studies almost exclusively focused on headache relief after dosing. No data are available on whether early intervention affects the duration from headache onset to peak and headache severity at peak.
Methods.— Adult migraineurs were enrolled in this observational study from multi-site headache clinics. Patients recorded their migraine experiences via an electronic diary over 1 month. Patients reported the time and pain severity at onset, dosing, and peak. We used a linear mixed model to evaluate the impact of the timing of treatment and to adjust for covariates and correlation of observations within subjects.
Results.— A total of 182 patients reported 970 migraine episodes, 620 of which were treated before headaches progressed to peak. Mean time from headache onset to peak varied from 1.9 hours to 8.9 hours for patients treated within 15 minutes of onset and those who waited for 4 or more hours, respectively. However, early intervention was not associated with reduced headache severity at peak. In multivariate analysis, early treatment, use of triptans, and mild migraine headache in the past 3 months were significantly associated with shorter time from onset to headache peak. A separate model indicated that the timing of medication was not associated with the duration between dosing and headache peak, but use of triptans shortened the time from dosing to headache peak.
Conclusions.— Early treatment and use of triptans may lead to shorter duration from migraine headache onset to its peak but did not alleviate headache severity at peak. This could result in decreased migraine burden by reducing total migraine headache duration.     

Obesity in the pediatric headache population: a multicenter study

Objective.— To examine the prevalence of obesity, the relationship between weight compared with headache frequency and disability, and effect of weight change on headache outcomes within a pediatric headache population.
Background.— Headache and obesity are both common conditions in children and adults. Research in adults has suggested a relationship between the 2 conditions. This relationship has not yet been explored within a pediatric population. The effect of obesity and weight change on headache outcomes may have important implications for clinical care.
Method.— Data on height, weight, age, and gender, as well as headache frequency and disability, were collected on 913 consecutive patients at 7 pediatric headache centers, the body mass index (BMI) calculated and the BMI percentile determined. The same data were collected on patients seen at 3- (n = 213) and 6-month (n = 174) follow-up for comparative analysis.
Results.— The prevalence of overweight patients at initial visit did not significantly differ from the general pediatric population. BMI percentile was significantly correlated with headache frequency and disability at initial visit, although the correlations were relatively small. For children who were obese or at risk for overweight as initial visit, change in BMI was significantly positively correlated with change in headache frequency at 3- and 6-month follow-up.
Conclusions.— Obesity is associated with headache frequency and disability in the pediatric headache population. For children who are overweight, weight loss can contribute to a reduction in headaches over time. Clinicians should consider child weight status in providing care for pediatric headache.     

The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients

BackgroundSubarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP).ObjectivesTo assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP.MethodWe conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation.ResultsOf 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%–100%) sensitivity and 37.0% (95% CI, 33.8–40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%–100%) and 37.3% (95% CI, 34.1%–40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%–90.2%) and 98.2% (95% CI, 96.1%–99.3%), respectively.ConclusionsThe OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.     

Clinical predictors of poor 30-day headache outcomes after an emergency department visit for acute post-traumatic headache

PurposeWe investigated clinical risk factors that predict poor 30-day headache outcomes among patients evaluated in the emergency department (ED) for post-traumatic headache (PTH).MethodsThis was an analysis of data from a randomized, placebo-controlled study of IV metoclopramide + diphenhydramine for acute PTH. Patients were enrolled during an ED visit and received telephone follow-up with a structured questionnaire 30 days later. The primary outcome was frequency of headaches 30 days after ED discharge. We used multivariable logistic regression models to determine which clinical variables were associated with frequent headaches at 30 days.ResultsIn total, 160 patients were enrolled in the study. 134 (84%) patients completed the 30-day questionnaire and were included in the analysis, including 90 females and 44 males. 30 patients (22%, 95% CI = 0.16 to 0.30) reported frequent headaches at 30-day follow-up. In the multivariable analysis, female sex (OR = 4.03, 95% CI = 1.23±13.13), patients who blamed themselves for their injury (OR = 0.13, 95% CI = 0.04±0.45), and patients who were unsure if they sustained loss of consciousness during the traumatic incident (OR = 5.63, 95% CI = 1.89±16.78) were found to be associated with poor 30-day outcomes. Medication received in the ED and age were not associated.ConclusionsMore than 1 out of five patients treated in the ED for acute PTH experienced frequent headaches 30 days later. Women and patients who were uncertain as to whether they had experienced loss of consciousness were at increased risk of frequent PTH. Blaming oneself for the head trauma was associated with less frequent PTH.     

Pediatric Migraine: Abortive Management in the Emergency Department

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.     

Canadian Headache Society criteria for the diagnosis of acute migraine headache in the ED—do our patients meet these criteria?

INTRODUCTION: We previously reported that many patients who present to the ED with "migraine" headache do not meet the International Headache Society criteria (IHSC) for the diagnosis of acute migraine. Objective The aim of the study was to compare the frequency for which ED patients with migraine headache meet the Canadian Headache Society criteria (CHSC) vs the IHSC. METHODS: This was a prospective, observational study, performed at a community ED. Consecutive patients who presented to study authors with a chief complaint of headache were enrolled. Historical/clinical data were collected on a standardized form. Ninety-five percent confidence intervals (95% CIs) were calculated and Fisher exact test was used as appropriate. RESULTS: One hundred eighty-nine patients were enrolled in this study. Mean age was 38 years. Females comprised 69% of patients. Thirty-seven percent of patients had prior ED visits for headaches. A positive family history of migraines was present in 35% of patients. Diagnostic imaging was previously performed in 44 of the enrollees to evaluate the cause of their headaches. A total of 43 (23%) patients had a prior diagnosis of migraine. Overall CHSC was met in 18% of patients, compared with 15% of patients who met IHSC. Discharge diagnosis of migraine was made in 41% of patients. Of these patients, 33% met CHSC and 28% met IHSC (P=.30). For patients with discharge diagnosis of migraine, 33% of females and 36% of males fit CHSC (P=.53), whereas 26% and 36% met IHSC (P=.34), respectively. For patients with a prior diagnosis of migraine, 32% met CHSC and 26% met IHSC (P=.24). Patients with a prior diagnosis of migraine and/or a discharge diagnosis of migraine met CHSC 31% (95% CI, 22%-40%) of the time vs 25% for the IHSC (95% CI, 16%-34%) (P=.26). Four patients without a discharge and/or previous diagnosis of migraine met CHSC; 3 met IHSC. CONCLUSIONS: In our study population, only a minority of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and/or IHSC to standardize ED patients for headache research may be limited.