Health resource utilization of the emergency department headache "repeater"

OBJECTIVE: To document the health resource utilization of patients who repeatedly use emergency department services for headache care. BACKGROUND: Patients with headache who frequently use emergency department services may differ from patients with more typical, episodic migraine. Previous studies of health resource utilization have often failed to distinguish the high utilizer as a specific subset of the migraine population. DESIGN: Retrospective review of urgent care/emergency department charts, clinic charts, and pharmacy rosters. PATIENTS AND METHODS: Patients who made three or more visits for headache to an urgent care/emergency department (UC/ED) facility for headache over a 6-month study period were identified and designated as "repeaters" for this study. Pharmacy profiles and appointment histories of 52 of the 54 repeaters whose records were available were reviewed for the 12 months prior to the study period. RESULTS: Over the 6-month study period, 518 patients visited the UC/ED 1004 times for primary headache complaints. Fifty-four (10%) repeaters made 502 visits (50% of total visits; mean 9.3, range 3-50). In the 12 months prior to the study period, 52 of these repeaters made 1832 visits to the UC/ED or clinic (mean 35.2, range 0-178): 1458 (79.6%) were headache related, and 1271 (69.4%) of all visits were to the UC/ED. An estimated 12-month cost for all visits was $183,760. Pharmacy rosters showed use of narcotics in 41 of the 52 patients (annual mean +/- SD, 613 +/- 670 tablets), benzodiazepines in 30 patients (500 +/- 486 tablets), and butalbital products in 27 patients (395 +/- 590 tablets). Mean daily use of all symptomatic medications combined was 3.9 +/- 3.2 doses/day. CONCLUSION: Health resource utilization of emergency department headache repeaters is predominantly headache-related acute care. Associated medication overuse is frequently present. Efforts to improve care for patients with headache will benefit from distinguishing the high utilizer as a subset of the migraine population.     

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.     

Osmophobia in juvenile primary headaches

This study was planned to investigate the prevalence of osmophobia in juvenile headache sufferers and to analyse the diagnostic utility of osmophobia in order to distinguish migraine without aura from episodic tension-type headache. We examined 305 consecutive patients presenting at our Paediatric Headache Centre. A semistructured questionnaire was given to 275 selected patients affected by migraine or tension-type headache. The prevalence of osmophobia during attacks was 18.5%, mainly in migraine patients (25.1%) vs. those with tension-type headache (8.3%). Osmophobia showed more specificity than phonophobia or photophobia in the differential diagnosis between migraine and tension-type headache. In conclusion, this study demonstrates that osmophobia resulted in a symptom with poor sensitivity (27.1%) but high specificity (92%) that could become a supportive diagnostic criterion even in children for the differential diagnosis between migraine without aura and tension-type 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.     

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.     

Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches

Nitroglycerin administration provokes spontaneous-like migraine attacks in migraine and cluster headache (CH) patients. Nitroglycerin-induced migraine-like headache has been used as an experimental model of migraine. In this paper, we evaluate the possibility of using the nitroglycerin provocative test (NPT) as a supportive measure in the diagnosis of primary neurovascular headaches by assessing its reliability on a large population and adopting strict criteria for rating the response as positive or negative. Our population consisted of 197 migraineurs, 42 subjects suffering from cluster headache and 53 healthy controls. In migraine without aura, the test sensitivity was 82.1%, specificity 96.2% and accuracy 85.5%, while in subjects suffering from migraine with aura, the reliability of the NPT was less satisfactory (sensitivity 13.6%, specificity 96.2% and accuracy 72%). In CH patients tested during the active phase of the disease the sensitivity was 80.6%, specificity 100% and accuracy 92.9%. NPT is an easy, low-cost and reliable method for supporting the diagnosis of migraine without aura and cluster headache.     

Pentraxin 3 level in acute migraine attack with aura: Patient management in the emergency department

ObjectivesWe investigated the state of inflammation, PTX3 level and other routine inflammatory markers (high sensitivity C-reactive protein [hsCRP], and white blood cells [WBC]), in patients who presented to the emergency department (ED) with migraine. We also investigated the relationship between the clinical presentation, PTX3 level, and other routine inflammatory markers in the emergency management of these patients.MethodsThe study included 44 patients (group 1) who presented to the ED due to a migraine attack with aura and 44 controls (group 2) with similar demographic characteristics.ResultsThe WBC count was 8.82 ± 2.10 × 109/L in group 1 and 7.85 ± 2.04 × 109/L in group 2. The mean PTX3 level was 11.57 ± 3.99 ng/mL in patients who presented at the ED with a migraine attack, and 4.59 ± 1.28 ng/mL in controls. The differences values of WBC and PTX3 between the two groups were significant (respectively; P = 0.031, P < 0.001). ROC analyses indicated significant results for PTX3 as a marker for acute migraine attack. It had a sensitivity of 93% and specificity of 84% at a cut-off value of 5.80 ng/mL.ConclusionThis is the first study to investigate plasma levels of PTX3 in patients with acute migraine. PTX3 as a biomarker may be used as an additional examination to the current subjective criteria to support the diagnosis of patients presenting to the ED with an acute migraine attack.     

The epidemiology of migraine: a retrospective study in Italian emergency departments

This study was conducted to measure the frequency of contact with emergency departments in Italy because of migraine, and to compare the initial diagnosi s of headache with the diagnosis after application of the International Headache Society (IHS) criteria. A retrospective observational method was used, consisting of an analysis of the records of patients admitted to nine Italian emergency departments during different 4-month periods in 1994. Comparison of the initial diagnosis with the diagnosis after application of the IHS diagnostic criteria was performed. More than 31 million emergency department contacts were reported in Italy during 1994. In the same year, 543 630 patients visited the nine emergency departments enrolled in the study, with 169 569 of these contacts occurring in the 4-month period analyzed in the study. We excluded from the analysis all cases of secondary headache fully recognized at the emergency department admission (ie, traumas, intracranial pathology, systemic diseases). The total number of patients included in our analysis was 1043 (0.6%). The 934 patients who could be fully evaluated were initially classified as having migraine; cluster headache; headache not otherwise specified; or diagnosed in the emergency department as suffering from headache, but reclassified by other departments as suffering from a different disease. After retrospective application of the IHS classification, the diagnostic distribution was modified, revealing that 18% of patients with migraine and 5% with cluster headaches had previously been classified as having headache not otherwise specified; a further 6% of cases with migraine and 0.4% of patients with cluster headache had previously been classified as having secondary headaches. The diagnosis of headache not otherwise specified was made with notable frequency, indicating the limits of emergency department logs and the difficulty in carrying out a retrospective analysis and reassessment of diagnosis. The majority (88%) of patients assessed had not taken drugs for headache in the 48 hours before the emergency department contact, suggesting that in Italy emergency departments are used instead of a visit to the general practitioner. Nonsteroidal anti-inflammatory drugs were the most frequently prescribed drugs in the emergency departments for this group of diagnoses. The research revealed, on the one hand, that headache is a numerically significant phenomenon in the emergency department setting and, on the other, the need to apply prospective designs to this kind of survey.     

Patients with pulmonary hypertension presenting to the emergency department

ObjectivesPulmonary hypertension (PH) patients represent a complex subset of patients in the emergency department (ED), yet little is known about their presentations and outcomes. The objective of this study is to analyze the demographics, dispositions and the rates of return visits for PH patients visiting the ED, focusing on PH patients identified as having high frequency visits.MethodsWe performed a retrospective cohort analysis of all patients with ICD-9-CM and ICD-10-CM codes corresponding to PH presenting to an academic medical center emergency department during a 21-month period. The primary outcome was patients with high frequency ED visits, defined as 4 or more visits in a 12-month period. Secondary outcomes included ED dispositions, return ED visits, hospital length of stay, and in-hospital mortality.ResultsSix hundred and eighty four unique patients with a coded diagnosis of PH visited the emergency department a total of 1447 times. Eighty-four patients (12.28%) were identified as having high frequency visits. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and having Group 1 PH. PH patients’ admission rate was substantial at 56.60%, and their inpatient mortality was increased (6.7% vs 3.7% for all admissions from ED, P < 0.0001).ConclusionPH patients in this study had frequent return ED visits, as well as elevated admission and readmission rates. Factors associated with high frequency ED visits included male sex, liver disease, rheumatologic disease, and Group 1 PH. PH patients also had increased mortality rates compared to the general ED population.     

Evaluating the use and timing of opioids for the treatment of migraine headaches in the emergency department

The objective of this study was to evaluate the throughput times of patients administered opioids for the treatment of migraine headaches in the frequent emergency department (ED) visitor. A retrospective review of ED patient records was conducted. Repeat patients were significantly more likely to receive opioids as a treatment, receive multiple doses of opioids, and receive opioids as the initial pharmacological treatment compared to non-repeaters. Patients administered opioids, regardless of repeater status, had significantly longer ED stays; 142 min (95% confidence interval [CI] 124–160) vs. 111 min (95% CI 93–129), respectively, p = 0.015. Patients given multiple doses of opioids had significantly longer ED stays than patients given a single dose of an opioid; 191 min (95% CI 156–225) vs. 125 min (95% CI 101–149), respectively, p = 0.003. Delayed administration of opioids did not result in longer ED stays in those patients eventually treated with opioids. Administration of opioids for migraine headache may result in longer ED stays when compared with non-opioid migraine treatments. Judicious use of opioids as a treatment for migraine headaches is recommended.     

Primary headache in Emergency Department: prevalence, clinical features and therapeutical approach

Headache is one of the most common reported complaints in the general adult population and it accounts for between 1% and 3% of admissions to an Emergency Department (ED). The overwhelming majority of patients who present to an ED with acute primary headache (PH) have migraine and very few of them receive a specific diagnosis and then an appropriate treatment. This is due, in part, to a low likelihood of emergency physicians diagnosing the type of PH, in turn due to lack of knowledge of the IHS criteria, and also the clinical condition of the patients (pain, border type of headache, etc.) In agreement with the literature, another interesting aspect of data emerging from our experience is that few of the ED PH patients are referred to headache clinics for diagnosis and treatment, especially if they present with high levels of disability. This attitude promotes the high–cost phenomenon of repeater patients that have already been admitted to the ED for the same reason in the past. This is statistically important because it involves about 10% of the population with PH.     

A validation study of an Italian version of the ID Migraine: preliminary results

Migraine is a highly prevalent and disabling disease that is substantially undiagnosed in primary care. Recently, the ID Migraine, a self–administered questionnaire, was shown to be a valid and reliable screener for migraine in primary care in the USA. To validate an Italian version of the ID Migraine, we planned a multicentric study, evaluating at least 220 patients affected by various form of headache. The responses to the questionnaire were compared with the diagnosis of headache made by a headache specialist blind to the result of the questionnaire. Sensitivity, specificity, and positive and negative predictive values for migraine were calculated. The statistical analysis on 140 patients now examined showed a very good performance of the ID Migraine with high sensitivity: 0.94 (95% CI: 0.89–0.95), specificity: 0.70 (95% CI: 0.54–0.86) and positive predictive value: 0.89 (0.82–0.95). If confirmed, these results would establish ID Migraine as a valid screening instrument for migraine in Italian headache patients and warrant further investigation in primary care to assess the validity of this ID screener in Italian population.     

Chest Pain A Manifestation of Migraine

Background

Chest pain is an alarming symptom; it justifies many visits to the emergency department (ED). The etiology is often unknown. Chest wall pain in the presence of migraine headache, although not a common occurrence, is intriguing when it resolves with antimigraine treatment.

Objectives

To characterize the manifestations and outcomes and investigate the relationship between chest wall pain and headache as a manifestation of migraine exacerbation.

Methods

Among patients visiting our ED, we identified those individuals whose pain originated in the chest wall in the setting of migraine exacerbation. Patients with clinical indications for specific treatments were dispositioned accordingly. Control of symptoms including chest pain and headache with antimigraine agents was considered the primary outcome. A prospective follow-up via telephone interview and medical records review was performed.

Results

We collected a convenience sample of 33 patients. All manifested migraine headache with an earlier onset than the chest pain, and all had taken medications prior to visiting the ED. Twelve patients reported a higher visual analog scale score for the headache than for the chest pain. Still, chest pain was the main complaint. The chest pain originated at the chest wall. Ten patients received sublingual nitroglycerin or opiates, or both; no pain relief was reported. However, all symptoms resolved with metoclopramide. On follow-up, 6 patients reported recurrence of chest pain with subsequent migraines.

Conclusions

Chest pain can be a complication of migraine. The treatment should be focused on migraine control. Migraine should be included in the differential diagnosis of chest pain.     

Posterior Ischemic Optic Neuropathy Associated With Migraine

Anterior ischemic optic neuropathy is a well-recognized clinical syndrome that has been described in patients after an episode of migraine with visual aura (classic migraine) and, less commonly, after an episode of visual aura without headache (acephalgic migraine). Little emphasis, however, has been placed on migraine associated retrobulbar or posterior ischemic optic neuropathy. We report two cases of visual loss presumed to be due to posterior ischemic optic neuropathy that occurred In the setting of otherwise typical migraine episodes. We review the English language literature on Ischemic optic neuropathy associated with migraine. Although most cases of ischemic optic neuropathy associated with migraine are of the anterior variety, posterior ischemic optic neuropathy should be considered in the differential diagnosis of any patient with acute loss of vision and evidence for a retrobulbar optic neuropathy, during or after an attack of migraine headache or following an otherwise typical episode of visual aure without headache (acephalgic migraine).     

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.     

Computed tomography pulmonary angiography in the diagnosis of acute pulmonary embolism in the emergency department

This study was undertaken to evaluate the use of computed tomography pulmonary angiography (CTPA) in patients with pulmonary embolism (PE) who were followed in the emergency department (ED). The files and computer records of 850 patients older than 16 years of age who were seen in the Hacettepe University Hospital ED between April 10, 2001, and December 1, 2005, and who required CTPA for PE prediagnosis and/or another diagnosis, were studied retrospectively. PE was identified by CTPA in 9.4% of 416 women and in 5.8% of 434 men. A significant difference (P< .05) was noted in the women and men in whom PE was detected. The mean age of the patients was 58.13±17.88 y (range, 16–100 y). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for clinical susceptibility to PE among patients who underwent CTPA were assessed at 95.3%, 48.2%, 13%, and 99.2%, respectively. CTPA was done for different reasons: aortic aneurysm dissection (n=1), cough distinctive diagnosis (n=1), dyspnea distinctive diagnosis (n=6), chest pain distinctive diagnosis (n=3), PE prediagnosis (n=51), and other reasons (n=2). Also, sensitivity, specificity, PPV, and NPV were found to be 95.4%, 16.2%, 14.4%, and 96%, respectively, for D-dimer. CTPA, which is accessible on a 24-h basis in the ED, is a valuable tool for the diagnosis of PE.