Emergency department evaluation of headache

Telemedicine application to headache: a critical review

BACKGROUND

Migraine affects more than a billion people all over the world and requires critical employment of healthcare resources. Telemedicine could be a reasonable tool to manage people suffering from headaches, and it received a big push from the COVID-19 pandemic.

OBJECTIVE

This review aims to propose a practical approach for the virtual management of these patients.

METHODS

To do this, we conducted a literature search, including 32 articles relevant to the topic treated in this review.

RESULTS

The most challenging step in telemedicine applied to practical neurology remains the clinical assessment, but through a careful headache history and a recently proposed entirely virtual neurological assessment, this hitch can be easily overcome. Electronic diary compilations and virtual administration of disability-measuring scales, conversely, are the key features of effective long-term follow-up although we do not have apps that met the criteria of scientific reliability. Furthermore, tele-rehabilitation seems to be effective and has demonstrated to be a solution to alternatively treat chronic patients at home, and can be considered part of the remote management of headache patients. Moreover, virtual management of headaches finds an application in specific communities of patients, as pediatric patients and for rural communities of low- and middle-income countries suffer from health disparities, with inadequate resources and knowledge gaps.

CONCLUSION

Telemedicine could be promising for patients with no regular or convenient access to headache specialists and seems to be a priority in managing migraine patients to avoid non-urgent hospitalizations.

The role of unenhanced CT alone for the management of headache in an emergency department. A feasibility study

OBJECTIVE

To determine whether unenhanced CT alone could be sufficient for the screening of patients admitted with a suspicion of secondary headache in an emergency center.

MATERIAL AND METHODS

A feasibility study including consecutive patients admitted to our emergency department for acute non-traumatic headache, in whom a brain CT was required by the emergency physician, was conducted over a 3-month period of time. Patients with a suspicion of intracranial pathology, which can only be depicted by i.v. images (arterial dissection, venous thrombosis, or postoperative complication) were recorded but excluded from analysis. All patients underwent both unenhanced and i.v. enhanced cerebral CT, including CT angiography. Unenhanced CTs were reviewed by two radiologists, blinded to the clinical data, to the radiological reports and to the i.v. enhanced images. Unenhanced CT were sorted by the radiologists into three groups: (1) normal CT, (2) benign finding that could explain headache without need of injection of contrast media, (3) evidence of an intracranial pathology, requiring further imaging. Results were compared to i.v. enhanced CT images.

RESULTS

A brain CT was required in 105 patients (34 males, 71 females) during the study period, 74 (70%) of them met our inclusion criteria. Fifty-nine (80%) were sorted in group 1 (normal), four (5%) in group 2, 11 (15%) in group 3. No further finding that could explain acute headache was found on i.v. CT images in patients of group 1 or 2. A significant pathology was confirmed by i.v. CT in all patients of group 3.

CONCLUSION

This feasibility study suggests that a normal unenhanced CT might be sufficient to exclude the cause of headache in the initial screening of a selected group of patients admitted with cephalalgia. It compels researchers to perform further prospective studies to confirm the current data on a larger amount of patients.

Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency department?

BACKGROUND

Health information exchange (HIE) is advocated as an approach to reduce unnecessary testing and improve quality of emergency department (ED) care, but little evidence supports its use. Headache is a specific condition for which HIE has theoretical benefits.

OBJECTIVE

To determine whether health information exchange (HIE) reduces potentially unnecessary neuroimaging, increases adherence with evidence-based guidelines, and decreases costs in the emergency department (ED) evaluation of headache.

DESIGN

Longitudinal data analysis

SUBJECTS

All repeat patient-visits (N = 2,102) by all 1,252 adults presenting with headache to a Memphis metropolitan area ED two or more times between August 1, 2007 and July 31, 2009.

INTERVENTION

Use of a regional HIE connecting the 15 major adult hospitals and two regional clinic systems by authorized ED personnel to access the patient's record during the time period in which the patient was being seen in the ED.

MAIN MEASURES

Diagnostic neuroimaging (CT, CT angiography, MRI or MRI angiography), evidence-based guideline adherence, and total patient-visit estimated cost.

KEY RESULTS

HIE data were accessed for 21.8 % of ED patient-visits for headache. 69.8 % received neuroimaging. HIE was associated with decreased odds of diagnostic neuroimaging (odds ratio [OR] 0.38, confidence interval [CI] 0.29-0.50) and increased adherence with evidence-based guidelines (OR 1.33, CI 1.02-1.73). Administrative/nursing staff HIE use (OR 0.24, CI 0.17-0.34) was also associated with decreased neuroimaging after adjustment for confounding factors. Overall HIE use was not associated with significant changes in costs.

CONCLUSIONS

HIE is associated with decreased diagnostic imaging and increased evidence-based guideline adherence in the emergency evaluation of headache, but was not associated with improvements in overall costs. Controlled trials are needed to test whether specific HIE enhancements to increase HIE use can further reduce potentially unnecessary diagnostic imaging and improve adherence with guidelines while decreasing costs of care.

Acute headache in the emergency department

In the acute setting, the primary objective is to decide whether the headache is primary, secondary but benign (for example a headache associated with a cold), or secondary to a potentially life-threatening cause (subarachnoid hemorrhage (SAH), bacterial meningitis, intracranial hypertension). The cornerstone of headache diagnosis is the interview with the patient, followed by a thorough physical examination. These two first clinical steps determine the need for investigation, immediate with inpatient care or on an outpatient basis, and the treatment to recommend, acutely and for future attacks in the case of primary headache. The indication for referral to a neurologist for long-term follow-up is assessed. Headaches can be separated into four groups: (1) recent onset and thunderclap; (2) recent onset with progressive installation: (3) well known to the patient and episodic (attacks with headache-free periods, as in episodic migraine or cluster headache); and (4) chronic daily headaches (more than 3 months, more than 15 days of headache per month). Headaches with a recent onset and judged unusual or worrisome by the patient (even one with frequent headaches) must raise the suspicion of a secondary cause and need to be investigated. Headaches that continue for months or years are more often primary, but secondary causes need to be ruled out in certain cases.

Risk stratification of non-traumatic headache in the emergency department

OBJECTIVE

To determine the diagnostic accuracy of an algorithm structured in four clinical scenarios to discriminate benign primary headaches from serious secondary non-traumatic headaches (NTH) in the emergency department (ED).

BACKGROUND

NTH is usually a benign symptom but can occasionally result in serious outcome making the disposition of patients with NTH difficult in the ED.

DESIGN AND METHODS

Consecutive adults patients referring to 8 EDs of the Emilia-Romagna region in Italy for NTH as the chief complaint were recruited in the study for a 30-day period. ED physicians attributed to each patient one of the four clinical scenarios (1, 2 and 3 identifying serious secondary headaches and scenario 4 identifying benign primary headaches) or an undetermined scenario when none of the four scenarios applied. Reference standards of the study were the head CT scan and a follow-up telephone interview after three months by the ED admission.

RESULTS

The test was administered to 256 out of 302 (85%) eligible patients. The analysis (scenario 1,2,3 vs scenario 4) was based on 180 patients who completed the follow-up showing a sensitivity of 100% (95% confidence interval, 81% to 100%) and a specificity of 64% (56% to 71%). The likelihood ratio for a positive test was 2.67 (2.15 to 3.31) and the likelihood ratio for a negative test was 0.04 (0.003 to 0.64).

CONCLUSIONS

An algorithm based on four clinical scenarios can be administered to the majority of patients presenting to the ED with the chief complaint of NTH. The algorithm showed a good accuracy in identifying patients with non-life threatening causes of headache and could be used as a risk stratification tool to improve clinical decision- making. Further studies are required to validate this diagnostic algorithm.

Concordance of historical questions used in risk-stratifying patients with headache

STUDY OBJECTIVE

We sought to determine whether the manner and order in which historical questions used to risk stratify for subarachnoid hemorrhage are asked significantly alter the response/concordance.

METHODS

Adult patients complaining of headache in the emergency department were presented with 1 of 2 questionnaires each containing 2 variations of the pertinent question and differing only in their order. Data were primarily analyzed using the kappa statistic to determine whether rates of concordance are greater than would be expected by chance alone. And, as a secondary outcome, a sample of 120 was predetermined to be adequate to achieve 80% power in detecting a difference of 20% to 25% between questionnaires comparing the influence of order on concordance.

RESULTS

The agreement corrected for chance for version 2, kappa = 0.51, is higher than the agreement corrected for chance for version 1, kappa = 0.28, a difference of 0.23 with a 95% confidence interval (-0.03 to 0.49; P = .08; SE, 0.13). The percentages of patients who answered the questions concordantly were 60% and 75%, respectively, for versions 1 and 2. The difference is 15% with a 95% confidence interval of (-2% to 32%, P = .08).

CONCLUSION

Although not statistically significant, our study indicates that up 38% answer these 2 very similar questions discordantly. Also, there appears to be a higher degree of concordance (15%) when patients are first asked, "When was the last time you had a headache this bad?"

Treatment of Headaches in the ED With Lower Cervical Intramuscular Bupivacaine Injections: A 1-Year Retrospective Review of 417 Patients

OBJECTIVE

The primary objective of this retrospective chart review is to describe 1 year's experience of an academic emergency department (ED) in treating a wide spectrum of headache classifications with intramuscular injections of 0.5% bupivacaine bilateral to the spinous process of the lower cervical vertebrae.

BACKGROUND

Headache is a common reason that patients present to an ED. While there are a number of effective therapeutic interventions available for the management of headache pain, there clearly remains a need for other treatment options. The intramuscular injection of 1.5 mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has been used to treat headache pain in our facility since July 2002. The clinical setting for the study was an academic ED with an annual volume of over 75,000 patients.

METHODS

We performed a retrospective review of over 2805 ED patients with the discharge diagnosis of headache and over 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004. All adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of their headache were gleaned from these 2 larger databases and were included in this retrospective chart review. A systematic review of the medical records was accomplished for these patients.

RESULTS

Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 417 patients. Complete headache relief occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No significant relief was reported in 57 patients (13.7%) and headache worsening was described in 4 patients (1%). Overall a therapeutic response was reported in 356 of 417 patients (85.4%). Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes. Associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and allodynia were also commonly relieved.

CONCLUSION

Our observations suggest that the intramuscular injection of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical spinous process appears to be an effective therapeutic intervention for the treatment of headache pain in the outpatient setting.

Headache related to brain tumors

Headache is one of the most common somatic complaints of patients seeking medical care. Most headaches are not of serious cause and can be diagnosed easily with a good history and physical examination. The challenges to the physician are to determine when underlying intracranial pathology may be causing the symptoms and signs, and to identify the few patients in whom a tumor is the cause of the headache. The subject of headache in patients with brain tumors has been reviewed in neurologic textbooks and in several investigations before, as well as after, modern imaging diagnostic techniques became available. Headache can also manifest as an acute or chronic complication of radiation treatment and/or chemotherapy in patients with intracranial neoplasm, but there are few data in the literature specifically addressing this subject. This article provides an overview of headache in patients with primary and secondary brain tumor, including headache characteristics, the putative mechanism for these headaches, the role of diagnostic testing, and the general principles of management.

Headache management--are we doing enough? An observational study of patients presenting with headache to the emergency department

OBJECTIVES

To identify the causes of acute headache presenting to the emergency department (ED), assess the adequacy of history, examination, and investigation, and determine which clinical features are predictive of secondary headache.

METHOD

A retrospective study of alert (GCS>or=14) patients presenting with headache, to an ED over a one year period. Patients were followed up for three months. The adequacy of history, examination, and investigation were compared with published standards. Analysis using Bayes's theorem determined which clinical features were predictive of secondary headache.

RESULTS

Headache in alert patients accounted for 0.5% (n = 353) of new patient episodes, 81.2% (n = 280) of patients had a primary headache disorder. One patient (0.3%) had an adequate history recorded. No patient had a complete examination recorded. Seventy seven (21.8%) patients underwent computed tomography of the head; 80.5% (n = 62) were normal. Lumbar puncture was performed in 23 (6.5%) cases; 18 (78.3%) were normal. A number of clinical features were found to be predictive of secondary headache.

CONCLUSION

Headache is an uncommon symptom in alert patients presenting to the ED. The recorded history, examination, and subsequent investigation do not comply with published standards. A number of predictive features have been identified that may permit the development of a clinical prediction rule to improve the management of this patient group.

Céphalées dans un contexte d’urgence

Headaches constitute one of the most frequent reason of consultation. Their causes are extremely varied. The first step consists in the analysis of the characteristics of the pain and the associated signs in order to distinguish primary and secondary headaches. Primary headaches, including migraines and tension-type headaches are the most frequent types and do not require imaging evaluation. Secondary headaches are related to an organic cause and require specific investigations. In case of suspected symptomatic or secondary headaches, brain imaging plays an important role in the etiologic work-up. The main purpose of imaging in an emergency setting is to diagnose a life-threatening disease.

Droperidol vs. prochlorperazine for the treatment of acute headache

To determine if droperidol i.v. is as effective as prochlorperazine i.v. in the emergency department (ED) treatment of uncomplicated headache, a randomized, controlled, blinded study was conducted in the Emergency Departments of two urban teaching hospitals. Patients >or= 18 years old with crescendo-onset headache were eligible for inclusion. Ninety-six patients (48 in each group) were randomized to receive droperidol 2.5 mg i.v. or prochlorperazine 10 mg i.v. Baseline characteristics were similar between the two study groups. For the main study outcome, 83.3% in the droperidol group and 72.3% in the prochlorperazine group reported 50% pain reduction at 30 min (p <.01; one-sided test of equivalence). The mean decrease in headache intensity was 79.1% (SD 28.5%) in the droperidol group and 72.1% (SD 28.0%) in the prochlorperazine group (p =.23). It is concluded that droperidol i.v. provided a similar reduction of headache as achieved with prochlorperazine i.v. with a similar incidence of akathisia.

Clinical warning criteria in evaluation by computed tomography the secondary neurological headaches in adults

Our aims were to investigate the frequency of intracranial lesions detected by cranial computed tomography (CT-scan) amongst adult patients who had clinical warning criteria (CWC) for secondary neurological headaches and to determine the importance of CWC in predicting a possible lesion on CT-scan. Seventy consecutive patients with headache exhibiting CWC were included in this prospective study. The CWC included: (i) increase in the intensity and frequency of headache; (ii) abrupt onset of headache; (iii) persistence of headache despite analgesics; (iv) alteration of the characteristics of headache; and (v) presence of focal neurological symptoms or findings. The mean age of the patients was 46.5 years; the female-to-male ratio was 1.5. Of the patients, 35.7% had a neurological cause identified by CT-scan, and 64.3% had normal CT-scan. In the patients without lesion, of headaches, 64.4% were primary, and 35.6% were from undefined headache group. Although, of the above criteria, only the 5th was different markedly in the patients with lesion than the patients without lesion, in evaluation by CT-scan the secondary neurological headaches in adults, all CWC should look for absolutely in their history and physical examination.

Models of headache and their implications for treatment using manual therapies

Headaches represent symptom collections reflecting various mechanisms. True pathology causing headache is comparatively rare and therefore headache symptoms generally reflect functional disturbances. Models of headache pathogenesis may lead to therapeutic interventions, or be extrapolated from successful therapeutic interventions. These can provide a basis for research and case management. If we consider symptom expression as a manifestation of a threshold response and headache sufferers as a population with lowered threshold, therapeutic approaches may be oriented to changing the thresholds. Headache symptoms may also represent the sensitivity to other triggers, which make it easier to reach a similar symptom threshold. Treatment would then be oriented to changing the response to the triggers. This paper presents models of manual therapies related to headache treatment and discusses research directions, relation to medical models of headache and a discussion of clinical considerations for treatment. Since individuals with headaches may represent a broad spectrum of etiologies, these models may be utilized in developing and fine-tuning individual programs of treatment as well as guiding future research. Manual therapies have significant potential relative to managing headaches. There are differences in application and technique that may be considered when approaching individual presentations. Understanding the mechanisms behind different models may provide a basis for fine-tuning therapeutic algorithms for individual presentations.

Evaluation and management of headache in the emergency department

In the ED, correct diagnosis is the necessary foundation on which specific therapy is based. There is no substitute for obtaining a thorough history and examining the patient competently. Patients with a past history of primary headaches, such as migraine, also may be afflicted with (new) secondary headaches. Although efficiency is desirable from the perspective of ED management, a thoughtful approach complemented by the judicious selection of tests is compatible with that goal as well as achieving the desired outcome of accurate diagnosis and relief of pain. Arrangements for long-term follow-up are important.

Extraoral facial pain

Craniofacial pain is a common chief complaint and is among the most frustrating diagnostic and treatment challenges encountered by emergency physicians. The efficient development of a differential diagnosis, the delivery of appropriate and effective therapies, and the appropriate referral of patients who present with craniofacial pain from extraoral sources are discussed. Disease descriptions, a diagnostic workup format, and acute management protocols are presented for the more common craniofacial pain entities.