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Zhong XM, Zhao LC, Peng LL, Li L, Li CQ. Rationale for issuing neuroimaging requests for patients with primary headaches in China. Brain Behav 2024; 14:e3583. [PMID: 38841826 PMCID: PMC11154824 DOI: 10.1002/brb3.3583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024] Open
Abstract
OBJECTIVE To investigate the prevalence of neuroimaging in patients with primary headaches and the clinician-based rationale for requesting neuroimaging in China. DATA SOURCES AND STUDY SETTING This study included patients with primary headaches admitted to hospitals and clinicians in China. We identified whether neuroimaging was requested and the types of neuroimaging conducted. STUDY DESIGN This was a cross-sectional study, and convenience sampling was used to recruit patients with primary headaches. Clinicians were interviewed using a combination of personal in-depth and topic-selection group interviews to explore why doctors requested neuroimaging. DATA COLLECTION We searched for the diagnosis of primary headache in the outpatient and inpatient systems according to the International Classification of Diseases-10 code of patients admitted to six hospitals in three provincial capitals by 2022.We selected three public and three private hospitals with neurology specialties that treated a corresponding number of patients. PRINCIPLE FINDINGS Among the 2263 patients recruited for this study, 1942 (89.75%) underwent neuroimaging. Of the patients, 1157 (51.13%) underwent magnetic resonance imaging (MRI), 246 (10.87%) underwent both head computed tomography (CT) and MRI, and 628 (27.75%) underwent CT. Fifteen of the 16 interviewed clinicians did not issue a neuroimaging request for patients with primary headaches. Furthermore, we found that doctors issued a neuroimaging request for patients with primary headaches mostly, to exclude the risk of misdiagnosis, reduce uncertainty, avoid medical disputes, meet patients' medical needs, and complete hospital assessment indicators. CONCLUSIONS For primary headaches, the probability of clinicians requesting neuroimaging was higher in China than in other countries. There is considerable room for improvement in determining appropriate strategies to reduce the use of low-value care for doctors and patients.
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Affiliation(s)
- X. M. Zhong
- Chengdu Second People's HospitalChengduChina
- Department of NeurologyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - L. C. Zhao
- Chengdu Second People's HospitalChengduChina
| | - L. L. Peng
- Chengdu Second People's HospitalChengduChina
| | - L. Li
- Department of NeurologyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - C. Q. Li
- Department of NeurologyThe Second Affiliated Hospital of Chongqing Medical UniversityChongqingChina
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Ganti L, Veluri SC, Stead TS, Rieck R. Ominous Causes of Headache. Curr Pain Headache Rep 2024; 28:73-81. [PMID: 38091239 DOI: 10.1007/s11916-023-01202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 03/10/2024]
Abstract
PURPOSE OF REVIEW While primary headaches like migraines or cluster headaches are prevalent and often debilitating, it's the secondary headaches-those resulting from underlying pathologies-that can be particularly ominous. This article delves into the sinister causes of headaches, underscoring the importance of a meticulous clinical approach, especially when presented with red flags. RECENT FINDINGS Headaches, one of the most common complaints in clinical practice, span a spectrum from benign tension-type episodes to harbingers of life-threatening conditions. For the seasoned physician, differentiating between these extremes is paramount. Headache etiologies covered in this article will include subarachnoid hemorrhage (SAH), cervical artery dissection, cerebral venous thrombosis, meningitis, obstructive hydrocephalus, and brain tumor.
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Affiliation(s)
- Latha Ganti
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
- University of Central Florida College of Medicine, Orlando, FL, USA.
- Envision Healthcare, Nashville, TN, USA.
| | | | - Thor S Stead
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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3
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The diagnostic values of red flags in pediatric patients with headache. Brain Dev 2022; 44:512-519. [PMID: 35568652 DOI: 10.1016/j.braindev.2022.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/08/2022] [Accepted: 04/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Headache is a common complaint in childhood and adolescence. Differentiating benign primary headaches from ominous secondary headaches is often difficult. Clinicians usually seek red flags to determine the need for neuroimaging. We aimed to evaluate the diagnostic values of red flags in pediatric headaches. METHODS We retrospectively reviewed the medical records of 1510 pediatric patients (1470 with primary headache, 40 with secondary headache) presenting with headache and underwent neuroimaging from two centers between March 2010 and December 2019. RESULTS The secondary-headache group exhibited significantly higher frequencies of abnormal neurologic signs/symptoms (40.0% vs 6.8%, p < 0.001), Valsalva maneuver/exercise-induced headache (15.0% vs 4.9%, p = 0.004), headache with vomiting (35.0% vs 17.9%, p = 0.006), and onset under age 6 (25.0% vs 10.3%, p = 0.003) than the primary-headache group, with the following positive likelihood ratio (PLR): 5.88, 3.06, 1.96, and 2.42, respectively. The sensitivity values were as follows: abnormal neurologic signs/symptoms (16/40, 40.0%), headache with vomiting (14/40, 35.0%), onset under age 6 (10/40, 25.0%), and Valsalva maneuver/exercise-induced headache (6/40, 15.0%). The overall sensitivity for ominous secondary headaches requiring surgical treatment was 86.2% (25/29). CONCLUSIONS Certain red flags, including abnormal neurologic signs/symptoms, Valsalva maneuver/exercise-induced headache, headache with vomiting, and onset under age 6, were more prevalent in the secondary-headache group; nonetheless, their sensitivity values and PLR were relatively low. Notwithstanding, considering these red flags' high overall sensitivity for ominous secondary headaches, neuroimaging in patients presenting these red flags should rely on careful follow-up of symptom progression.
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Abstract
Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.
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Reynolds EL, Burke JF, Evans L, Syed FI, Liao E, Lobo R, Cooper W, Charleston L, Callaghan BC. Headache neuroimaging: A survey of current practice, barriers, and facilitators to optimal use. Headache 2022; 62:36-56. [PMID: 35041218 PMCID: PMC9053599 DOI: 10.1111/head.14249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 09/15/2021] [Accepted: 10/07/2021] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The objective of this study was to understand current practice, clinician understanding, attitudes, barriers, and facilitators to optimal headache neuroimaging practices. BACKGROUND Headaches are common in adults, and neuroimaging for these patients is common, costly, and increasing. Although guidelines recommend against routine headache neuroimaging in low-risk scenarios, guideline-discordant neuroimaging is still frequently performed. METHODS We administered a 60-item survey to headache clinicians at the Veterans Affairs health system to assess clinician understanding and attitudes on headache neuroimaging and to determine neuroimaging practice patterns for three scenarios describing hypothetical patients with headaches. Descriptive statistics were used to summarize responses, stratified by clinician type (physicians or advanced practice clinicians [APCs]) and specialty (neurology or primary care). RESULTS The survey was successfully completed by 431 of 1426 clinicians (30.2% response rate). Overall, 317 of 429 (73.9%) believed neuroimaging was overused for patients with headaches. However, clinicians would utilize neuroimaging a mean (SD) 30.9% (31.7) of the time in a low-risk scenario without red flags, and a mean 67.1% (31.9) of the time in the presence of minor red flags. Clinicians had stronger beliefs in the potential benefits (268/429, 62.5%) of neuroimaging compared to harms (181/429, 42.2%) and more clinicians were bothered by harms stemming from the omission of neuroimaging (377/426, 88.5%) compared to commission (329/424, 77.6%). Additionally, APCs utilized neuroimaging more frequently than physicians and were more receptive to potential interventions to improve neuroimaging utilization. CONCLUSIONS Although a majority of clinicians believed neuroimaging was overused for patients with headaches, many would utilize neuroimaging in low-risk scenarios with a small probability of changing management. Future studies are needed to define the role of currently used red flags given their importance in neuroimaging decisions. Importantly, APCs may be an ideal target for future optimization efforts.
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Affiliation(s)
- Evan L Reynolds
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Lacey Evans
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Faiz I Syed
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Radiology, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Eric Liao
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Remy Lobo
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wade Cooper
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry Charleston
- College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
- Jefferson Headache Center, Philadelphia, Pennsylvania, USA
| | - Brian C Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Kristoffersen ES, Faiz KW, Hansen JM, Tronvik EA, Frich JC, Lundqvist C, Winsvold BS. The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey. J Headache Pain 2021; 22:136. [PMID: 34763647 PMCID: PMC8582095 DOI: 10.1186/s10194-021-01350-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/28/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND General practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management. METHODS We invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey. RESULTS 367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients. CONCLUSION The knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.
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Affiliation(s)
- Espen Saxhaug Kristoffersen
- Department of General Practice, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.
| | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Jakob Møller Hansen
- Danish Knowledge Centre on Headache Disorders, Rigshospitalet-Glostrup, University, of Copenhagen, Glostrup, Denmark
| | - Erling Andreas Tronvik
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology, National Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norway
| | - Jan C Frich
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Christofer Lundqvist
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bendik Slagsvold Winsvold
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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7
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Hervás C, Somovilla A, Gago-Veiga AB, Alonso J, Del Arco C, Vivancos J, Quintas S. Headache History-Taking in an Emergency Department: Impact Evaluation of a Training Session. PAIN MEDICINE 2021; 22:1864-1869. [PMID: 33769531 DOI: 10.1093/pm/pnaa483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Headache represents about 25% of the total neurological consultations at the emergency department (ED). Up to 80% of these consultations are represented by primary headaches, in which an accurate and directed history-taking may help reach the specific diagnosis avoiding unnecessary complementary tests and reducing diagnostic latencies. METHODS We carried out a training session on headache management at the ED, focusing on history-taking and primary headaches' diagnoses and management. We retrospectively compared the number of variables included in the medical reports and the percentage of patients who were diagnosed and/or treated for a primary headache between two months before and two months after the training session. RESULTS A total of 369 medical histories were analyzed for this study (196 before and 173 after the training session). The number of essential variables regarding pain characteristics included in the medical reports showed a post-intervention increment from 4.34 ± 1.224 to 4.67 ± 1.079 (P = .007) and the number of total items registered also increased from 6.87 ± 1.982 to 7.53 ± 1.686 (P = 0.001). The percentage of patients that were given a specific diagnosis for primary headache showed an increment of 11.8% (P = .002) in the post-intervention group. CONCLUSION Educational interventions can improve history-taking in headache patients in the ED. This fact grants them as potential efficient measures to optimize patient management at Emergency Room.
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Affiliation(s)
- Carlos Hervás
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria, Madrid, Spain
| | - Alba Somovilla
- Neurology Department, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana Beatriz Gago-Veiga
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
| | - Jaime Alonso
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria, Madrid, Spain
| | - Carmen Del Arco
- Emergency Department, Hospital Universitario de la Princesa, Madrid, Spain
| | - Jose Vivancos
- Department of Neurology, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria, Madrid, Spain
| | - Sonia Quintas
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Madrid, Spain
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8
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Altiparmak T, Nazliel B, Caglayan HB, Tokgoz N, Gurses AA, Ucar M. Headache features of cerebellar ischemic strokes: Clinical and radiological-experiences of a single center. J Clin Neurosci 2021; 88:173-177. [PMID: 33992180 DOI: 10.1016/j.jocn.2021.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/14/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022]
Abstract
The prevalence of headache in stroke has been reported between 8% and 34%. Determining the prevalence, features, and effects on prognosis of cerebellar ischemic strokes that presented with headache solely and/or with other cerebellar signs were the aims of our study.All patients diagnosed with cerebellar ischemia were included. Electronic medical records were reviewed. Patients have been followed up for 6th month. Descriptive statistics were generated. A total of 4763 patients were evaluated retrospectively, 200 patients had cerebellar ischemia and 22 patients of these cerebellar ischemias (11%) had a headache at initial presentation. Ataxia, dysarthria, dysmetria were the most common neurological findings. There was no significant difference whether ischemic lesion single or multiple and whether above or below 1.5 cm diameter. Ischemic lesions generally were in cortical/ juxtacortical layer. According to vascular perfusion areas, 54.5% patients' ischemia was located in PICA (posterior inferior cerebellar artery) territory. Patients presenting with a headache, predominantly had left hemispheric (vermian > hemispheric > pedincular) involvement. Although these patients generally had high modified Rankin Scale scores at the first evaluation, they had low NIHSS (National Institutes of Health Stroke Scale) scores (0-5), and nearly all patients recovered, with low mRS at the 6-month follow-up.Cerebellar ischemic strokes with headache presentation are significantly prevalent in patients with left hemispheric, cortical/juxtacortical, PICA perfusion territory ischemias and are associated with low morbidity unless there was a conscious disorder. We believe this is one of the first studies that evaluated the clinical and radiological parameters of cerebellar stroke patients with headache.
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Affiliation(s)
- Taylan Altiparmak
- Gazi University, Faculty of Medicine, Department of Neurology, Ankara, Turkey.
| | - Bijen Nazliel
- Gazi University, Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Hale Batur Caglayan
- Gazi University, Faculty of Medicine, Department of Neurology, Ankara, Turkey.
| | - Nil Tokgoz
- Gazi University, Faculty of Medicine, Department of Radiology, Ankara, Turkey
| | - Aslı Akyol Gurses
- Gazi University, Faculty of Medicine, Department of Neurology, Ankara, Turkey
| | - Murat Ucar
- Gazi University, Faculty of Medicine, Department of Radiology, Ankara, Turkey
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9
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Schytz HW, Amin FM, Jensen RH, Carlsen L, Maarbjerg S, Lund N, Aegidius K, Thomsen LL, Bach FW, Beier D, Johansen H, Hansen JM, Kasch H, Munksgaard SB, Poulsen L, Sørensen PS, Schmidt-Hansen PT, Cvetkovic VV, Ashina M, Bendtsen L. Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 3rd edition, 2020. J Headache Pain 2021; 22:22. [PMID: 33832438 PMCID: PMC8034101 DOI: 10.1186/s10194-021-01228-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/12/2021] [Indexed: 12/19/2022] Open
Abstract
Headache and facial pain are among the most common, disabling and costly diseases in Europe, which demands for high quality health care on all levels within the health system. The role of the Danish Headache Society is to educate and advocate for the needs of patients with headache and facial pain. Therefore, the Danish Headache Society has launched a third version of the guideline for the diagnosis, organization and treatment of the most common types of headaches and facial pain in Denmark. The second edition was published in Danish in 2010 and has been a great success, but as new knowledge and treatments have emerged it was timely to revise the guideline. The recommendations for the primary headaches and facial pain are largely in accordance with the European guidelines produced by the European Academy of Neurology. The guideline should be used a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organized in Denmark. This description is followed by sections on the characteristics, diagnosis and treatment of each of the most common primary and secondary headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular challenges regarding migraine and female hormones as well as headache in children are addressed.
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Affiliation(s)
- Henrik W Schytz
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark.
| | - Faisal M Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Louise Carlsen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Stine Maarbjerg
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Nunu Lund
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Karen Aegidius
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Lise L Thomsen
- Specialized Pediatric Clinic, Jægersborgvej 66B, 2. Sal, 2800, Kgs. Lyngby, Denmark
| | - Flemming W Bach
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Dagmar Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Hanne Johansen
- The Migraine and Headache Association (https://www.hovedpineforeningen.dk), Toftehøj 90, 6470 Sydals, Denmark
| | - Jakob M Hansen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark.,National Headache Knowledge Center, Danish Headache Center, Rigshospitalet-Glostrup, Valdemar Hansen Vej 5, Glostrup, 2600, Denmark
| | - Helge Kasch
- Department of Neurology, Spinal Cord Injury Centre of Western Denmark, Viborg Hospital, Viborg, Denmark
| | - Signe B Munksgaard
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Lars Poulsen
- General Practice, Clinic Laegehuset Nr. Broby, Saksenballe 5, 5672, Broby, Denmark
| | | | | | - Vlasta V Cvetkovic
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
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10
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Yayıcı Köken Ö, Danış A, Yüksel D, Aksoy A, Öztoprak Ü, Aksoy E. Pediatric headache: Are the red flags misleading or prognostic? Brain Dev 2021; 43:372-379. [PMID: 33187753 DOI: 10.1016/j.braindev.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/14/2020] [Accepted: 10/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Symptoms and findings called orange or red flags may indicate the etiology of pediatric headaches and may point to a life-threatening situation requiring urgent treatment and thus can alter patient management. These findings can be either misleading or prognostic for clinicians. We aimed to identify the etiology and prognostic value of orange/red flags in pediatric patients. METHODS This study included 810 children with headaches who underwent neuroimaging due to the existence of orange/red flags. Their hospital records were examined to obtain demographical, clinical, laboratory data, and re-classify the headaches and determine orange/red flags on admission. RESULTS Secondary causes were identified in 17.0% (n: 138) of patients, however, those who were diagnosed with a life-threatening headache that required emergency treatment were 5.2% of all patients and 30.4% of the patients diagnosed with a secondary headache. Those with secondary headaches and with life threatening secondary headaches which required urgent treatment were younger (p = 0,018, p = 0,022), had more emergency department visits (p < 0,001), and acute onsets (p < 0,001). Red flags, like systemic symptoms (p < 0,001), sudden onset (p = 0,023, p = 0.039), papilledema (p < 0,001), and progressive headaches (p = 0,048, p = 0.006), were more common with secondary headaches and its subgroup, while headache awakening from sleep (p = 0.009) and family history of primary headache (P > 0,001) were more common in primary headaches. No correlation existed between the number of red flags and etiology. However, older age (p = 0,001) and a shorter duration between symptoms and admission (p = 0,032), and the number of emergency service visits (p = 0,020) increased with increasing red flags. CONCLUSIONS Physicians always look for flags when they encounter patients with headaches, which is a common symptom, so as not to overlook anything. However, red flags do not always mean that the underlying cause requires emergency treatment and the severity of the cause is not correlated with the number of flags.
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Affiliation(s)
- Özlem Yayıcı Köken
- Department of Pediatric Neurology, Ankara City Hospital, Children's Hospital, Ankara, Turkey.
| | - Ayşegül Danış
- Deparment of Pediatric Neurology, SBU, Dr. Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Deniz Yüksel
- Deparment of Pediatric Neurology, SBU, Dr. Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Ayşe Aksoy
- Deparment of Pediatric Neurology, Ondokuz Mayıs University, Faculty of Medicine, Samsun, Turkey
| | - Ülkühan Öztoprak
- Deparment of Pediatric Neurology, SBU, Dr. Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Erhan Aksoy
- Deparment of Pediatric Neurology, SBU, Dr. Sami Ulus Research and Training Hospital, Ankara, Turkey
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11
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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12
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Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings. J Clin Med 2020; 9:jcm9082621. [PMID: 32806717 PMCID: PMC7464980 DOI: 10.3390/jcm9082621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 02/03/2023] Open
Abstract
The aim of this study was to measure prevalence, to describe underlying etiologies, and to assess radiological findings, focusing on significant intracranial abnormality (sICA). This was a prospective study of unselected adult patients admitted to the emergency department (ED) in a tertiary care hospital where all presenters were systematically interviewed about their symptoms. We attributed nontraumatic headache with neuroimaging to four groups: Normal or no new finding, extracranial abnormality, insignificant intracranial abnormality, or significant intracranial abnormality. sICA was defined as “needing acute therapy”, “needing follow-up neuroimaging”, or “clinically important neurological disorder”. Among 11,269 screened ED presentations, the prevalence of nontraumatic headache was 10.1% (1132 patients). Neuroimaging (cCT and/or cMRI) was performed in 303 patients. Seventy (23.1% of scanned; 6.2% of all headache patients) patients had sICA. Etiologies were cerebrovascular disease (56%), intracranial bleeding (17%), tumors (14%), infection (9%), and others (6%). Short-term outcome was excellent, with 99.3% in-hospital survival in patients with and 99.4% in patients without neuroimaging, and 97.1% in sICA; 1-year survival in outpatients with neuroimaging was 99.2%, 99.0% in outpatients without, and 88.6% in patients with sICA. Factors associated with sICA were age, emergency severity index (ESI) of 1 or 2, Glasgow coma score (GCS) under 14, focal neurological signs, and a history of malignancy. Prevalence of headache and incidence of sICA were high, but survival after work-up for nontraumatic headache was excellent in the 94% patients without sICA. Due to the incidence of sICA, extensive indication for neuroimaging in headache patients is further warranted, particularly in patients with risk factors.
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13
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Kristoffersen ES, Faiz KW, Winsvold BS. Neurology residents' knowledge of the management of headache. Cephalalgia 2019; 39:1396-1406. [PMID: 31067081 DOI: 10.1177/0333102419847973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In Norway, as in most other countries, the training program for clinical neurology has no mandatory headache program. Knowledge in headache management must therefore be acquired during everyday clinical training. The objectives of this study were to investigate neurology residents' knowledge of headache. METHODS A questionnaire survey was undertaken among neurology residents in Norway. RESULTS All 17 neurological departments in Norway participated, and 143 residents responded (86%). Sixty percent were women, mean age was 32.5 years, and the respondents had an average of 28 months clinical training in neurology. Fifty-six percent knew the approximate prevalence of migraine and chronic headache. Thirty-seven percent asked their patients about disability, quality of life, and social functioning at every consultation. Further, 72% would prescribe prophylaxis for chronic tension-type headache and 97% for very frequent migraine. One third wrongly stated that use of the most common headache prophylactics could lead to medication-overuse headache. Headache diaries were used regularly by 63% for diagnostic purposes, and 73% requested an MRI for all long-lasting headaches referred to neurological outpatient clinics. CONCLUSION Although a major public health problem, headache knowledge is moderate at best, and its management clearly varies. There is an unmet need for a better and more structured headache training program in Norway.
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Affiliation(s)
- Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Department of General Practice, HELSAM, University of Oslo, Oslo, Norway.,FORMI, Oslo University Hospital, Oslo, Norway
| | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Research Centre, Akershus University Hospital, Lørenskog, Norway
| | - Bendik Slagsvold Winsvold
- FORMI, Oslo University Hospital, Oslo, Norway.,Department of Research, Innovation and Education, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway
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14
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Young NP, Philpot LM, Vierkant RA, Rosedahl JK, Upadhyaya SG, Harris A, Ebbert JO. Episodic and Chronic Migraine in Primary Care. Headache 2019; 59:1042-1051. [PMID: 31032913 DOI: 10.1111/head.13543] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To inform migraine care model development by assessing differences between patients with chronic migraine (CM) and episodic migraine (EM) in the current state of treatment, disability, patient satisfaction, and quality improvement opportunities. BACKGROUND Efficient and focused use of scarce resources will be needed to address challenges within large populations of migraine patients. METHODS We deployed a cross-sectional survey study of randomly selected migraine patients within a community primary care practice. RESULTS There were 516 survey respondents (516/1804 [30%] response rate). CM patients were more likely than EM patients to report care from a neurologist (76/110 [69%] vs 229/406 [56%]; P = .0026), and higher disability according to the Migraine Disability Assessment and Headache Impact Test - 6 questionnaires (P < .0001). CM patients were less likely than EM patients to report overall satisfaction with care (16/110 [38%] vs 156/406 [66%], P = .0002), satisfaction with access to care (17/110 [33%] vs 176/406 [68%], P < .0001), and advice they needed (16/110 [31%] vs 160/406 [62%], P < .0001). Most patients with migraine had been offered triptan medications 377/516 (78%). Overall, 156/516 (31%) of individuals were currently taking any medication for migraine prevention, and 208/516 (40%) including botulinum toxin injections. CM patients were more likely to be taking preventive medication (39/110 [36%] vs 117/406 [29%], P = .0191) and report familiarity with the diagnosis of medication-overuse headache than patients with EM (80/110 [81%] vs 256/406 [69%], P = .0178). CONCLUSIONS We observed differences between patients with chronic and EM and expected care delivery improvement opportunities for migraine patients in primary care. CM patients report higher levels of disability and less satisfaction with access to perceived needed medical advice and care. These findings support the need to further develop and study novel care models to efficiently and effectively deliver high-quality care and expertise in limited supply to a diverse migraine population.
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Affiliation(s)
- Nathan P Young
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Lindsey M Philpot
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Robert A Vierkant
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jordan K Rosedahl
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Sudhindra G Upadhyaya
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ann Harris
- Mayo Clinic Survey Research Center, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Gadde JA, Cantrell S, Patel SS, Mullins ME. Neuroimaging of Adults with Headache: Appropriateness, Utilization, and an Economical Overview. Neuroimaging Clin N Am 2019; 29:203-211. [PMID: 30926111 DOI: 10.1016/j.nic.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
One of the most common reasons that a patient seeks out a health care provider for a neuroscience-related issue is headache. Not all patients can, or probably should, be imaged with headache. We must use an approach that attends to scientific evidence, accepted guidelines, and available resources. This approach should focus on quality, safety, appropriateness, and utilization. This article reviews and discusses the consideration of imaging adult patients with headache.
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Affiliation(s)
- Judith A Gadde
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Road NE, BG 20, Atlanta, GA 30322, USA.
| | - Sarah Cantrell
- Baylor Radiologists, CHI St Lukes, Texas Medical Center, 6720 Bertner Avenue, MC 2-270, Houston, Texas 77030, USA
| | - Sumir S Patel
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Road NE, BG 20, Atlanta, GA 30322, USA
| | - Mark E Mullins
- Department of Radiology, Emory University School of Medicine, 1364 Clifton Road NE, BG 20, Atlanta, GA 30322, USA
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