Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection

Influence of next-generation artificial intelligence on headache research, diagnosis and treatment: the junior editorial board members' vision - part 2

Part 2 explores the transformative potential of artificial intelligence (AI) in addressing the complexities of headache disorders through innovative approaches, including digital twin models, wearable healthcare technologies and biosensors, and AI-driven drug discovery. Digital twins, as dynamic digital representations of patients, offer opportunities for personalized headache management by integrating diverse datasets such as neuroimaging, multiomics, and wearable sensor data to advance headache research, optimize treatment, and enable virtual trials. In addition, AI-driven wearable devices equipped with next-generation biosensors combined with multi-agent chatbots could enable real-time physiological and biochemical monitoring, diagnosing, facilitating early headache attack forecasting and prevention, disease tracking, and personalized interventions. Furthermore, AI-driven advances in drug discovery leverage machine learning and generative AI to accelerate the identification of novel therapeutic targets and optimize treatment strategies for migraine and other headache disorders. Despite these advances, challenges such as data standardization, model explainability, and ethical considerations remain pivotal. Collaborative efforts between clinicians, biomedical and biotechnological engineers, AI scientists, legal representatives and bioethics experts are essential to overcoming these barriers and unlocking AI's full potential in transforming headache research and healthcare. This is a call to action in proposing novel frameworks for integrating AI-based technologies into headache care.

"Code Headache": Development of a protocol for optimizing headache management in the emergency room

BACKGROUND AND PURPOSE

Patients presenting at the emergency room (ER) with headache often encounter a hostile atmosphere and experience delays in diagnosis and treatment. The aim of this study was to design a protocol for the ER with the goal of optimizing the care of patients with urgent headache to facilitate diagnosis and expedite treatment.

METHODS

A narrative literature review was conducted via a MEDLINE search in October 2021. The "Code Headache" protocol was then developed considering the available characteristics and resources of the ER at a tertiary care center within the Spanish National Public Health system.

RESULTS

The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify patients based on suspected primary/secondary headaches and the need for pain treatment. Initial assessments, performed by the triage nurse, aim to first exclude potentially high morbidity and mortality etiologies (HEAD1 scale) and then expedite appropriate pain management (HEAD2 scale) based on scoring criteria. HEAD1 evaluates vital signs and symptoms of secondary serious headache disorders that can most benefit from earlier identification and treatment, while HEAD2 assesses symptoms indicative of status migrainosus, pain intensity, and vital signs. Subsequently, ER physicians employ a third assessment that reviews red flags for secondary headaches (grouped under the acronym 'PEACE') to guide the selection of complementary tests and aid diagnosis.

CONCLUSIONS

The Code Headache protocol is a much needed tool to facilitate quick clinical assessment and improve patient care in the ER. Further validation through comparison with standard clinical practice is warranted.

Headache diagnosis and treatment: A pilot knowledge and needs assessment among physical therapists

OBJECTIVE

The objective of this pilot study was to assess physical therapists' (PTs) knowledge and needs regarding headache diagnosis and management.

BACKGROUND

While there is significant research on physical therapy and cervicogenic headache, studies suggest that migraine is often under-recognized, misdiagnosed, and inadequately treated across society despite its high prevalence and burden. Because migraine commonly includes concurrent neck pain and/or vestibular symptoms, patients with migraine may present to PTs for treatment. Very little is known about PTs' headache and migraine education, knowledge, and clinical practices.

METHODS

A team of headache specialists and PTs adapted a previously used headache knowledge and needs assessment survey to help ascertain PTs' knowledge and needs regarding headache treatment. The cross-sectional survey was distributed online via Research Electronic Data Capture (REDCap) to PTs within a large healthcare system in Connecticut.

RESULTS

An estimated 50.5% (101/200) of PTs invited to complete the survey did so. Only 37.6% (38/101) of respondents reported receiving any formal headache or migraine education in their professional training, leading to knowledge gaps in differentiating and responding to headache subtypes. Only 45.5% (46/101) were able to identify that migraine is characterized by greater pain intensity than tension-type headache, and 22.8% (23/101) reported not knowing the duration of untreated migraine. When asked about the aspects of care they believe their patients with headache would like to see improved, PTs reported education around prevention and appropriate medication use (61/100 [61.0%]), provider awareness of the degree of disability associated with migraine (51/100 [51.0%]), and diagnostics (47/100 [47.0%]).

CONCLUSION

This sample of PTs from one healthcare system demonstrates knowledge gaps and variations in clinical practice for managing their patients with headache. Future research on integrating additional opportunities for headache education for physical therapists, including evidence-based behavioral therapies, is needed to ascertain whether it is likely to improve patient care.

Approach to the Diagnosis and Treatment of Headache

Headache is consistently one of the most common complaints reported by patients in the medical setting worldwide. Headache can be a symptom of another condition or illness, secondary to the disruption of homeostasis, or can be a primary disorder with inherent variability and patterns. Headache disorders, whether primary or secondary, can cause significant disability and loss of quality of life for those affected. As such, it is important for primary care providers to feel confident evaluating and treating patients with headache, especially given the limited access to Headache Medicine subspecialists.

Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study

OBJECTIVES

Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache.

METHODS

Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination.

RESULTS

5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%).

CONCLUSION

The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning.

TRIAL REGISTRATION NUMBER

ANZCTR376695.

How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department?

Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.

Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study

BACKGROUND AND IMPORTANCE

Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs).

OBJECTIVE

To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions.

DESIGN

Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019.

SETTING AND PARTICIPANTS

Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems.

OUTCOME MEASURES AND ANALYSIS

The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems.

MAIN RESULTS

The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r  = -0.248).

CONCLUSION

In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.

Common Clinical and Molecular Pathways between Migraine and Sarcoidosis

Migraine and sarcoidosis are two distinct medical conditions that may have some common biological and clinical pathways. Sarcoidosis is a chronic granulomatous disease characterized by the formation of granulomas in various organs, including the lungs, skin, cardiovascular system, lymph nodes, and brain. Migraine is a common comorbidity in sarcoidosis patients and a common neurological disorder characterized by recurrent headaches that can be accompanied by other symptoms, such as nausea, vomiting, and sensitivity to light and sound. There have been several reports of individuals with neurosarcoidosis experiencing migraines, though the exact relationship between the two disorders is not well understood. Both conditions have been associated with inflammation and the activation of the immune system. In sarcoidosis, the formation of granulomas is thought to be an immune response to the presence of an unknown antigen. Similarly, the pain and other symptoms associated with migraines are thought to be caused by inflammation in the brain and the surrounding blood vessels. There is also evidence to suggest an interplay of environmental and genetic factors playing a role in both conditions, but evidence is inconsistent with the hypothesis of shared genetic susceptibility. This review aims to illustrate common clinical and biological pathways between migraine and sarcoidosis, including inflammation and dysregulation of the immune system, with a focus on the cumulative burden of concurrent disorders and therapeutic implications.