Etiology and distribution of headaches in two Brazilian primary care units

OBJECTIVES: To determine (a) which patients seek primary care services with a complaint of headache, (b) the percentages of the various types of headache in this population, and (c) the impact of the care provided to these patients on the basic health care network. BACKGROUND: Headache is one of the most frequent symptoms reported in medical practice, resulting in significant medical services costs and loss of patient productivity, as well as reduced quality of life. METHODS: A prospective study was conducted in two towns (Ribeir?o Preto and S?o Carlos) in the State of S?o Paulo, Brazil. The participants in the study consisted of 6006 patients (52.4% women) with highly varied acute symptoms. The patients ranged in age from 14 to 98 years. RESULTS: Headache as the main complaint was reported by 561 (9.3%) of the patients considered, with 312 (55.6%) of those patients presenting with primary headache, 221 (39.4%) with headaches secondary to systemic disorders, and 28 (5.0%) with headaches secondary to neurological disorders. Migraine, the most prevalent primary headache, accounted for 45.1% of patients reporting headache as the single symptom. The most frequent etiologies of headaches secondary to systemic disorders were fever, acute hypertension, and sinusitis. The most frequent headaches secondary to neurological disorders were posttraumatic headaches, headaches secondary to cervical disease, and expansive intracranial processes. Of the 26 cases of drug abuse, 20 were secondary to alcohol (hangover). Headaches secondary to systemic disorders were more frequent in the extreme age ranges. CONCLUSIONS: Headache is a very frequent symptom among patients seen at primary health care units and should be considered a public health problem. The dissemination of the diagnostic criteria of the International Headache Society among primary health care physicians is urgently needed in order to avoid the repeated return of patients or their referral to more differentiated emergency units, which overburden an already insufficient health care network.     

Somatic symptoms in headache patients: the influence of headache diagnosis, frequency, and comorbidity

BACKGROUND: Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. METHODS: Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME-MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow-up data were obtained 6 months after consultation. RESULTS: Clinical diagnoses and PRIME-MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P<.001) and chronic daily headache (CDH) (6.3, P=.008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to 2 days per week had significantly higher somatic counts (P=.01). Six-month follow-up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P=.01 and 0.8, P=.003, respectively). CONCLUSION: Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.     

Computed Tomography in the Headache Patient: Is Routine Evaluation Really Necessary?

SYNOPSIS
Objective . To determine the likelihood ratio of a positive computed tomogram of the brain in the routine evaluation of headache patients.
Design . Consecutive patients with a chief complaint of headache were prospectively evaluated with computed tomography of the brain. Patients with headaches complicating other clinical disorders such as trauma, postictal state or known intracranial neoplasm were excluded.
Setting . Military tertiary care center.
Patients . Consecutive sample of 350 patients with a chief complaint of headache, regardless of the presence or absence of physical or neurologic signs, were referred for computed tomography of the brain. The patients were referred from a variety of inpatient and outpatient settings.
Results . Seven (2%) of the 350 patients had computed tomographic findings that were clinically significant. An additional 25 (7%) had positive computed tomographic findings, which were clinically insignificant for findings. All of the patients with significant computed tomographic findings had an abnormal physical or neurologic exam or unusual clinical symptoms.
Conclusion . Routine computed tomography of the brain in headache patients with normal physical and neurologic exams and no unusual clinical symptoms has a low likelihood ratio for discovering significant intracranial disease.     

Evidence-based diagnosis of nontraumatic headache in the emergency department: a consensus statement on four clinical scenarios

Objective.—To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches.
Background.—Many patients present to an ED with the chief complaint of headache. Causes of nontraumatic headache include life-threatening illnesses, and distinguishing patients with such ominous headaches from those with a primary headache disorder can be challenging for the ED physician.
Conclusion.—We present a consensus statement aimed to be a useful tool for ED doctors in making evidence-based diagnostic decisions in the management of adult patients with nontraumatic headache.
Methods.—A multidisciplinary work performed an extensive review of the medical literature and applied the information obtained to commonly encountered scenarios in the ED.     

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.     

Clues in the Differential Diagnosis of Primary vs Secondary Cough,Exercise, and Sexual Headaches

Activity‐related headaches can be provoked by Valsalva maneuvers (“cough headache”), prolonged exercise (“exertional headache”) and sexual excitation (“sexual headache”). These entities are a challenging diagnostic problem as can be primary or secondary and the etiologies for secondary cases differ depending on the headache type. In this paper we review the clinical clues which help us in the differential diagnosis of patients consulting due to activity‐related headaches. Cough headache is the most common in terms of consultation. Primary cough headache should be suspected in patients older than 50 years, if pain does not predominate in the occipital area, if pain lasts seconds, when there are no other symptoms/signs and if indomethacin relieves the headache attacks. Almost half of cough headaches are secondary, usually to a Chiari type I malformation. Secondary cough headache should be suspected in young people, when pain is occipital and lasts longer than one minute, and especially if there are other symptoms/signs and if there is no response to indomethacin. Every patient with cough headache needs cranio‐cervical MRI. Primary exercise/sexual headaches are more common than secondary, which should be suspected in women especially with one episode, when there are other symptoms/signs, in people older than 40 and if the headache lasts longer than 24 hours. These patients must have quickly a CT and then brain MRI with MRA or an angioCT to exclude space‐occupying lesions or subarachnoid hemorrhage.     

Space headache: a new secondary headache

Headache is a common, but rarely voiced, complaint during space flights, usually attributed to space motion sickness (SMS). We used a specifically designed questionnaire based on the criteria of the International Classification of Headache Disorders, 2nd edn (ICHD-II). Of the 16 male and one female astronauts who participated in the survey, 12 (71%) reported having experienced at least one headache episode while in space, whereas they had not suffered from headache when on earth. There were in total 21 space headache episodes, of moderate to severe intensity in 71%. In two astronauts (12%) the headache and associated symptoms would match the ICHD-II criteria for migraine and in three (18%) astronauts for tension-type headache; in 12 (70%) astronauts the headache was non-specific. The vast majority of headache episodes (76%) were not associated with symptoms of SMS. We conclude that space flights may trigger headaches without other SMS symptoms in otherwise 'super-healthy' male subjects. We propose to classify space headache as a separate entity among the secondary headaches attributed to disorders of homeostasis.     

A 22-Year-Old Woman With Chronic Daily Headaches

Tension-type headache is a common clinical complaint occurring in 78% of the general population. Chronic tension-type headache in adult patients is defined as attacks of headaches occurring on at least 15 days per month over a period of at least 3 consecutive months. The association between headaches and psychological factors represents a significant clinical problem that leads to a broader discussion about whether primary headaches could lead to anxiety or whether anxiety symptoms may precipitate primary headaches. This case highlights the positive outcomes associated with the appropriate identification and treatment of a comorbid psychiatric condition.     

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.     

Emergency department management of the acute headache

Headache is a common complaint of patients seeking care at an emergency department (ED). A survey of more than 16,755 walk-in patients at an ED showed that 323 (1.9%) had a chief complaint of migraine (1). Almost one sixth of these patients had used the ED more than once. In fact, migraineurs used the ED and other health care providers 2 to 5 times more than nonmigraineurs (2). Fortunately, headaches associated with significant morbidity and mortality occur infrequently (3). The ED physician must be able to address the patient's need for pain management and establish the correct diagnosis for the headache while also ruling out any possibility of organic disease or life-threatening illness. Potential problems include ensuring appropriate follow-up and avoidance of narcotic habituation.     

Emergency department management of the acute headache

Headache is a common complaint of patients seeking care at an emergency department (ED). A survey of more than 16,755 walk-in patients at an ED showed that 323 (1.9%) had a chief complaint of migraine (1). Almost one sixth of these patients had used the ED more than once. In fact, migraineurs used the ED and other health care providers 2 to 5 times more than nonmigraineurs (2). Fortunately, headaches associated with significant morbidity and mortality occur infrequently (3). The ED physician must be able to address the patient's need for pain management and establish the correct diagnosis for the headache while also ruling out any possibility of organic disease or life-threatening illness. Potential problems include ensuring appropriate follow-up and avoidance of narcotic habituation.     

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.     

Identification of Depression in an Inner-city Population Using a Simple Screen

Objectives: The purpose of this study was to compare a brief screening tool with physicians' usual practice in detecting depressive symptoms in patients presenting with somatic complaints to an inner-city emergency department. Depression is a major cause of morbidity and mortality in the United States. Underprivileged patients who rely on emergency departments for primary care remain at risk for undetected depression. Methods: This prospective observational study included all patients older than 18 years presenting to an urgent care clinic staffed by emergency physicians in an urban public hospital during an eight-week period. Clinically unstable patients and those with a chief complaint of depression were excluded. After consenting, patients completed a previously validated two-question screening tool for depression. Patients identified as having depressive symptoms were referred to social workers for evaluation for possible psychiatric intervention. Results: Of the 226 patients enrolled, 55% (124/226; 95% confidence interval [CI] = 48% to 61%) screened positive for depressive symptoms. Physicians identified 14% (31/226; 95% CI = 10% to 19%) as having depressive symptoms. The κ value was 0.22 (95% CI = 0.14 to 0.29). All patients but one identified as positive by the physicians screened positive on the screening tool. Patients who screened positive were referred to social workers. The physicians failed to identify 19 of the patients who needed further psychiatric care. Conclusions: Depressive symptoms are common among patients in urgent care settings with somatic complaints. A simple screening tool identified more patients for further evaluation than does physicians' usual practice.     

What clues are available for differential diagnosis of headaches in emergency settings?

The correct diagnosis of headache disorders in an emergency room is important for developing early management strategies and determining optimal emergency room activities. This prospective clinical based study was performed in order to determine demographic and clinical clues for differential diagnosis of primary and secondary headache disorders and also to obtain a classification plot for the emergency room practitioners. This study included 174 patients older than 15 years of age presenting in the emergency room with a chief complaint of headache. Definite headache diagnoses were made according to ICHD-II criteria. Classification and regression tree was used as new method for the statistical analysis of the differential diagnostic process. Our 174 patients with headache were diagnosed as basically primary (72.9%) and secondary (27.1%) headaches. Univariate analysis with cross tabs showed three important results. First, unilateral pain location caused 1.431-fold increase in the primary headache risk (p = 0.006). Second, having any triggers caused 1.440-fold increase in the primary headache risk (p = 0.001). Third, having associated co-morbid medical disorders caused 4.643-fold increase in the secondary headache risk (p < 0.001). It was concluded that the presence of comorbidity, the patient’s age, the existence of trigger and relaxing factors, the pain in other body parts that accompanies headache and the quality of pain in terms of location and duration were all important clues for physicians in making an accurate differentiation between primary and secondary headaches. This study was presented as an oral presentation at the 42nd Congress of Turkish Neurological Society in Antalya, 2006.     

The features and burden of headaches within a chiropractic clinical population: A cross-sectional analysis

ObjectivesThe aim of this study is to a) investigate the headache features and level of headache severity, chronicity, and disability found within a chiropractic patient population and b) to ascertain if patient satisfaction with headache management by chiropractors is associated with headache group or reason for consulting a chiropractor.Design and settingConsecutive adult patients with a chief complaint of headache participated in an online cross-sectional survey (n = 224). Recruitment was via a randomly selected sample of Australian chiropractors (n = 70). Headache features were assessed using International Classification of Headache Disorders criteria and level of headache disability measured using the Headache Impact Test instrument.ResultsOne in four participants (n = 57; 25.4%) experienced chronic headaches and 42.0% (n = 88) experienced severe headache pain. In terms of headache features, 20.5% (n = 46) and 16.5% (n = 37) of participants had discrete features of migraine and tension-type headache, respectively, while 33.0% (n = 74) had features of more than one headache type. ‘Severe’ levels of headache impact were most often reported in those with features of mixed headache (n = 47; 65.3%) and migraine (n = 29; 61.7%). Patients who were satisfied or very satisfied with headache management by a chiropractor were those who were seeking help with headache-related stress or to be more in control of their headaches.ConclusionMany with headache who consult chiropractors have features of recurrent headaches and experience increased levels of headache disability. These findings may be important to other headache-related healthcare providers and policymakers in their endeavours to provide coordinated, safe and effective care for those with headaches.     

Clinical Predictors of Significant Findings on Head Computed Tomographic Angiography

Background: Although head computed tomographic angiography (CTA) is a sensitive tool for the evaluation of neurological symptoms in the emergency department (ED), little is known about which clinical signs predict significant CTA findings. Objectives: To identify clinical factors that predict significant findings on head CTA in patients presenting to the ED with neurological complaints. Methods: Retrospective chart review of consecutive adult patients undergoing head CTA over a 6-month period in an urban, tertiary care ED with an annual volume of 76,000. Significant head CTA findings were defined as clinically significant neurological abnormalities undetected by previous imaging studies. Demographics, chief complaint, results of the neurological examinations (NE), and head non-contrast computed tomography (CT) results were used as predictors of significant head CTA. All predictors with a univariate p < 0.2 using Pearson's chi-squared were entered stepwise into a multivariable logistic regression including odds ratios (OR), with inclusion restricted to p < 0.05. Results: Chart review yielded 456 cases; 215 (47%) were male. Mean age was 62 (SD 20) years. There were 189 patients (41%) with abnormal CTAs. Multivariable logistic regression indicated five variables that predicted a clinically significant CTA: abnormal CT (OR 3.72), chief complaint of subarachnoid hemorrhage-type headache (OR 2.30), and motor deficit (OR 2.23), visual deficit (OR 2.23), and other focal deficit (OR 2.18) on NE. A chief complaint of trauma (OR 0.23) predicted a normal CTA. Conclusions: Specific historical and focal neurological findings are useful for predicting clinically significant findings on head CTA.     

Headache disability in orofacial pain patients

OBJECTIVE: To retrospectively examine the reported history of and the disability caused by headaches in patients presenting for evaluation and treatment of orofacial pain. BACKGROUND: More than 81% of patients with the chief complaint of pain in the orofacial region concomitantly report pain in other body locations. Among the comorbidities frequently reported with orofacial pain are a variety of different headaches types, including migraines, tension type headaches, and chronic daily headaches. The extent of the disability caused by those headache complaints in a large patient population is unknown. METHODS: The Migraine Disability Assessment (MIDAS) is administered to all patients as a part of the initial assessment at the Orofacial Pain Center. This investigation is retrospectively examined the reported history of and the disability caused by headaches in patients who presented for evaluation and treatment of orofacial pain in the Orofacial Pain Center, National Naval Medical Center, Bethesda, MD, between the dates of 1 September 2003 and 1 December 2004. RESULTS: In the present study 261 (61.3%) patients reported a headache complaint and 100 (38%) fulfilled the criteria for migraine with or without aura. MIDAS scores were reported by 55.3% of 426 patients with the mean score of 23.68. There were no significant differences in MIDAS scores in relation to the presence or absence of an intracapsular disorder. Patients with masticatory and/or cervical myalgia demonstrated significantly higher MIDAS scores when compared to patients without myalgia. CONCLUSIONS: These findings clearly demonstrate the necessity for evaluation of headache and related disability in orofacial pain patients.     

Psychiatric caseness is a marker of major depressive episode in general practice

Objective

Screening for a major depressive episode (MDE) in high-risk groups of patients within the primary care setting has been suggested by several Central Health Organizations. The objective of this study was to investigate whether patients rated as “psychiatric cases” by their general practitioner (GP) were likely to suffer from MDE and therefore qualified for systematic diagnostic screening.

Design

Cross-sectional survey of primary care patients assessed through depression screening questionnaires and GP consultations.

Setting

A total of 676 general practices in Denmark, Finland, Norway, and Sweden.

Subjects

A total of 8879 unselected primary care patients.

Main outcome measures

Sensitivity, specificity, and Youden Index of the GPs'' diagnoses of depression and psychiatric caseness versus patients'' MDE status.

Results

The proportion of primary care patients receiving a false-positive diagnosis of depression by their GP ranged from 12.4% to 25.2% depending on country. The corresponding numbers for the false-negative diagnoses were 0.5–2.5%. Among patients with MDE, GPs recognize the disease in 56–75% of cases. However, GPs recognize as many as 79–92% of patients with MDE as “psychiatric cases”.

Conclusions

This report confirms that misclassifications of MDE are common in the primary care setting. In addition, it shows that psychiatric caseness is a valid marker for the presence of MDE in primary care patients. This relationship should be considered in future screening recommendations.Key Words: Depression, diagnosis, family practice, mass screening, questionnairesPatients with a major depressive episode (MDE) are often overlooked in the primary care setting. Central Health Organizations suggest screening for MDE in high-risk categories of primary care patients. This study investigated whether patients rated as “psychiatric cases” by their GPs were likely to suffer from MDE and therefore qualified for systematic diagnostic screening.

• Misclassifications of MDE were common in the present sample of primary care patients.
• Among primary care patients with MDE, general practitioners (GPs) recognized the disease in 56–75% of the cases.
• Up to 92% of patients with MDE were identified as psychiatric cases by their GP. This relationship should be considered in future screening recommendations.

Major depressive episode (MDE) is the most common mental disorder in primary care [1]. General practitioners (GPs) play a crucial role in detecting and treating mental disorders, including MDE [2]. Diagnosis and treatment of MDE in primary care remains a difficult challenge for GPs and misclassifications are common. There are two types of misclassifications of MDE, namely false negative (patients meeting MDE criteria, but who are not recognized as depressed by their GPs) and false positive (perceived to suffer from MDE by the GPs without fulfilling the MDE criteria) [3–7]. These misclassifications have obvious adverse effects for the patients and procedures to minimize their likelihood of occurrence are required. The purpose of this study was to examine the GPs'' diagnostic capability in relation to MDE and to evaluate whether patients rated as “psychiatric cases” by their GP were likely to suffer from MDE.