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Headaches in the emergency department –a survey of patients' characteristics, facts and needs

• Irina Shestaritc^{2  na1},
• Daniela Ungaro^{ane  na1},
• John-Ih Lee^{3  na1},
• Loukas Lymperopoulos^{iv  na1},
• Lili Kokoti^{five  na1},
• Martina Guglielmetti^{6,vii  na1},
• Dimos Dimitrios Mitsikostas^{8  na1} &
• Christian Lampl ORCID: orcid.org/0000-0003-4340-3486 ^{9  na1}
• on behalf of the School of Avant-garde Studies of the European Headache Federation (EHF-SAS)

The Journal of Headache and Pain volume 20, Article number:100 (2019) Cite this article

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Abstract

Groundwork and aim

Headache is very often the cause for seeking an emergency department (ED). Yet, less is known most the different diagnosis of headache disorders in the ED, their management and treatment. The aim of this survey is to analyse the direction of headache patients in two different ED in Europe.

Methods

This retrospective survey was performed from September 2018 until Jan 2019. Patients were collected from the San Luca Hospital, Milan, Italy and the Ordensklinikum Barmherzige Schwestern, Linz, Republic of austria. Only patients with a not-traumatic headache, as the primary reason for medical clarification, were included. Patients were analysed for their complexity and range of exam, their diagnoses, acute treatment and overall efficacy rate.

Results

The survey consists of 415 patients, with a mean age of 43.32 (SD ±17.72); 65% were female person. Technical investigation was performed in 57.8% of patients. For acute handling non-steroidal-anti-inflammatory drugs (NSAIDs) were the most used, whereas triptans were not given. A chief headache disorder was diagnosed in 45.three% of patients, existence migraine the near common, merely in 32% of cases the diagnosis was non further specified. Life-threatening secondary headaches accounted for less than 2% of cases.

Conclusions

The vast majority of patients attending an ED because of headache are suffering from a principal headache disorder. Life-threatening secondary headaches are rare but seek attention. NSAIDs are past far the most common drugs for treating headaches in the ED, but not triptans.

Introduction

Headaches are one of the most challenging complaints in the emergency department (ED) bookkeeping for 1–4% of all ED visits [one,2,3,4]. Headache types, diagnostic procedures and acute handling may vary in different EDs throughout countries, depending on the catchment area, specific departments of the hospital, structure of their particular ED, in-house protocols and local medical staff. In addition, clinicians in the ED are busy, ordinarily with a express fourth dimension setting and in general facing two challenges: filtering patients who need further diagnostic evaluation, including neuroimaging and lumbar puncture in specific cases, as well as the aim of headache relief by adequate handling. Life-threatening conditions presenting with headache embrace cerebrovascular, encephalon mass effect and inflammatory-infection pathologies mainly, yet rare compared to primary headache disorders. To screen patients for a plausible secondary headache in ED, physicians should consider the suggested "cerise flag" symptoms in patients presenting with headache [v]. Ruby-red flag symptoms are numerous and do not include exclusively neurological signs. Moreover, potential co-morbidities, specific headache history and individualised patient characteristics should be considered. In a few studies exploring the frequency of secondary headaches in ED, approximately five% of patients with astringent headaches had a secondary headache [6], some of them life-threatening or severe disabling [seven]. However, the bulk of patients had a benign diagnosis. Published information nigh headache patients in the ED, their diagnoses and direction are rare, peculiarly when comparing different countries.

In this current study we provide results on characteristics and management of non-trauma headache patients in the ED of ii unlike European Union cities. These results were compared with the then far published surveys and critically discussed.

Methods

This cross-sectional cohort study was performed retrospectively from September 2018 until January 2019. Patients were collected from ii hospitals in Europe: the San Luca Hospital of Istituto Auxologico Italiano, Milan, Italian republic and the Ordensklinikum Barmherzige Schwestern, Linz, Austria.

The San Luca Hospital in Milan is a Scientific Institute for Hospitalisation and Intendance including a non-profit system for biomedical and loftier specialization hospital treatment. This ED consists of 3 different examination rooms. A cardiologist, nurses and other paramedics are in charge and a neurologist on call. In 2018, 11.073 patients visited the ED and the physicians examined 923 cases (mean) per calendar month.

The Ordensklinikum Barmherzige Schwester is a general hospital in Linz with 663 beds and 17 different departments and institutes. In the ED general practitioners, internal medicine physicians, neurologists and nurses are working in an interdisciplinary setting. The hospital has 8 specific access days per calendar month. In 2018, 26.978 patients visited the ED and the physicians examined 207 cases (mean) per month.

The study conformed to the revised upstanding principles of the Helsinki declaration and the Codex rules and guidelines for inquiry. Information technology is based on patients who participated in the inpatient assessment and treatment program in the both ED. During their outset appointment all patients participating in the survey provided written informed consent to use their information for the quality control, and to publish the data in anonymized course as office of the quality command process. Therefore, an ethics blessing was non obtained for the present analysis.

Patients were eligible for inclusion if they presented to the ED with an acute or longer lasting, disabling non-traumatic headache of any potential cause. The headaches were characterized with descriptive statistics calculated for patient demographic, clinical findings, investigations, and ED diagnosis. As analyses were considered exploratory, no formal adjustment for multiple comparisons was performed. In an exploratory analysis, both hospitals were compared, using the chi-square test, Fisher'south exact test, Pupil t-test, or Wilcoxon rank-sum examination as appropriate. Statistical significance was set at a < 0.05 (2-sided). Patients were analysed for their complication and range of examination, their diagnoses, astute treatment intervention and overall efficacy rate at discharge (Patients Global Impression (PGI) Q:" Have you lot been satisfied with the examination and treatment regime - Yes/No?").

Results

Demographics

The survey consists of 415 patients (184 patients from the San Luca Hospital and 231 patients from the Ordensklinikum Barmherzige Schwestern, Linz). 268 (65%) were female and 147 (35%) male, with a mean historic period of 43.32 (SD ±17.72; ranged from fifteen to 96 years). Overall, non-traumatic headache deemed for 3.2% of the full ED visits (3.5% in Linz and 2.9% in Milan), existence disproportionately more females (65% vs. 35%, p = .001). Eighty-two of all patients (19.8%) presented vomiting as a concomitant symptom. 5 patients (2.7%) had a history of non-headache specific trauma in their history (Table ane).

Table ane Demographics and patients characteristics

Full size table

Piece of work-up and treatment

Neurological examination was performed in 301 of patients (72.v%), statistically pregnant more than in Linz than in Milan ((197, 85.iii% vs 104; 56.5%, p = .000). Technical investigation was performed in 253 patients (sixty.ix%); 221 patients (53.ii%) had a non-contrast cranial CT, 12 patients (two.9%) received a cranial CT with boosted CT angiography and 7 patients (1.7%) underwent a brain MRI. A lumbar puncture was performed in v patients (1.2%). 30-5 patients (8.4%) were admitted to the local neurological department for further investigations, considering they had focal neurological symptoms. Other examinations consist of blood test (n = 333; 80%), ECG (n = 225; 54%), ENT and opthalmological test were done in 9 patients (2.2%).

For astute handling (north=408) non-steroidal-anti-inflammatory drugs were given in 237 patients (58.0%), acetaminophen in 58 patients (fourteen.2%), 2 patients (0.five%) received corticosteroids and 94 (23.0%) received other drugs (including aspirin, antiemetics, metamizol, paracetamol). Triptans were not given in any patients. Further therepeutic recommendations at discharge were shown in Table 2. The overall efficacy rate (PGI) was satisfactory in 195 patients (47.4%). A therapeutic recommendation at discharge was given in 401 patients (96.vi%).

Table 2 Therapeutic procedures

Full size tabular array

Diagnosis

The final diagnoses, according to the ICHD iii classification of headache disorders [eight] are shown in Table three. A primary headache was found in 188 patients (45.iii%), while ninety patients (21.7%) had a secondary headache, a trigeminal neuralgia was diagnosed in 4 patients (one.0%). Headache diagnosis was not further specified in 133 patients (32.0%).

Table iii Final diagnosis at belch

Total size table

287 (69.one%) were discharged at home, 84 (20.two%) has to be transferred to the ED curt-stay unit for further observation. Thirty-five patients (8.4%) were admitted to the neurological department for boosted investigation.

Discussion

In our current assay of patients visited the ED because of headache, in both hospitals migraine has been reported to be the most common cause (26%) of primary headaches. Similar migraine diagnosis rate in the EDs was institute in a cantankerous-exclusive Australian report [x]. In contrast to that, a recent published, big epidemiological US trial showed over a 10-year period of observation, that migraine was present in 63.5% of all headache presentations in an ED [seven]. I possible explanation for this major departure comes up from the American Migraine Written report published in 1998: Lipton and colleagues estimated that only 66% of migraine sufferers had ever consulted a doctor for headache [9], and one of the major causes for this is an insufficient outpatient intendance and/or low consultation rates. Therefore more than headache sufferers make a claim on ED to seek help for their burden. Other major findings, equally the predominance of female person headache patients in the ED, are in line with previous observations in the United states of america of America [6], in Australia [ten], also as in Brazil [11]. Compared to lower percentages (14.v% or 38%) establish in previous studies [4, 10] in our survey 53% patients received CT scans in the ED.

Vomiting was a frequent ascertainment in headache ED patients, which is explained by the fact that vomiting is one of the cardinal symptoms of migraine, and migraine is the most mutual crusade of primary headaches in the ED [iv, x]. Likewise, another study has reported a higher percentage of 31.vii% [10]. The percentage of life threatening secondary headache diagnoses (bleedings, meningitis/encephalitis) in our written report was below 2%, which is as well in understanding (< 3%) with previous studies published [4, 10].

Most 32% of the headaches in this study were simply labelled as "headache" without a more specific ICHD 3 diagnosis [8]. This is lower than the 44% reported by Chu and colleagues [10] and similar to the 36% reported by Friedman and colleagues [12], who conducted detailed structured patient interviews with the assist of trained inquiry assembly. However, the ratio of headache cases non further specified remains high in our survey, outside the expected limits. A possible reason may be related to the multi-professional staffing of the two hospitals. General practitioners, internal medicine physicians, cardiologists, and neurologists work together to provide a multidisciplinary approach for these patients; therefore not all headache patients were seen and managed by neurologists, or past a headache specialist. Furthermore, the physicians must be able to address the patient's need for hurting management in a very short and intense timeframe and exclude simultaneously any possibility of a life threatening affliction. The challenge in the busy setting of an ED is to determine inside a express corporeality of time, which patient is in need of immediate farther diagnostic work up in guild to exclude whatsoever secondary, dangerous headaches, that might have serious and irreversible health consequences, if diagnosis and treatment are delayed.

Surprisingly, 94% of our patients received non-specific simple analgesic drugs for acute headache therapy, but none received a triptan, although they were available in both ED. For patients presenting de novo to an ED for direction of migraine, emergency clinicians conspicuously have a broad armamentarium of therapeutic options. In these cases, we speculate emergency clinicians might choose to use non-specific simple analgesic drugs instead of triptans for one of the following reasons: (i) they believe that non-specific simple analgesic drugs are effective and appropriate for the acute handling of migraine; (two) they are concerned near adverse events of triptans; (iii) they are not sufficiently familiar with triptans; (iv) they adopt a treatment parentally administrated for faster efficacy and/or considering of vomiting (only sumatriptan is available in this formulation); (iv) ED were not supplied with any triptan. Withal, triptans were prescribed in ix patients (two%) at discharge. Reasons for the low awarding of triptans should be investigated in further studies. This could be of special interest for care managers, considering previously published data revealed that patients who received triptans had the shortest median length of stay in the ED [xiii].

In our setting 53% of patients had a CT head scan, which is very much higher than in other surveys [5, ten, 11]. Reasons for that may be complex. Physicians often piece of work under the pressure of time constraints, and initial assessment, including SNNOOPS 10 list [14] tin can be difficult, especially in patients with pre-existing neurological or psychological weather condition. Studies have reported difficulties in making a definite headache diagnosis in the setting of ED [15,16,17] without any CT scan of the brain. However, a conscientious history and physical examination remain the virtually important parts of the assessment of the headache patients in club to identify high-take chances patients and to exclude any secondary headache, that, if left without treatment, could take disastrous furnishings on the patient'due south wellness [7, 10]. Patients who have ane or more high-risk historical features or exam findings are considered to have a life-threatening condition requiring urgent diagnostic work-up [xviii, 19]. Red flag symptoms include neurological signs or symptoms (confusion, seizure, altered mental condition, loss of consciousness, asymmetric reflexes, focal neurologic deficits or visual deficits), meningism, fever, sudden and astringent onset of the headache or change in the characteristics of a known headache, advanced age (onset after 50 to 65 years), pregnancy or puerperium, coagulopathy, tumour history, positional headache, headache precipitated past sneezing, coughing or exercise, painful-centre with autonomic features, posttraumatic onset of headache, painkiller overuse or new drug at onset of headache and any systemic affliction including HIV infection and any immunosuppressed country in general [six, 10, xiv]. The European Headache Federation consensus reports the reasons and headache cases that may need technical investigation, as well as the required tests [5].

Study limitations and strengths

At that place are several limitations that should be addressed. Get-go, the written report was a retrospective information assay and all clinical data were nerveless past the treating physician and non by defended trained headache experts. Second, the treating physicians did non tape data. Eligibility was not verified, nor was missing cases specifically sought. Systematic choice bias is possible, simply unlikely given cases were enrolled in the ED 24 h per twenty-four hours by many clinicians across both sites. For the data collection, questions on clinical history were probably different in both centres, as there was no compatible and standardised questionnaire. Whether missing data may bias the results volition depend on whether the information were missing at random or not. The latter could be problematic. On the other hand, this is the offset survey conducted in Europe reporting existent discussion data for the management of headache in an ED setting. This information may trigger relevant organisations and health care designers to improve care delivered in ED.

Conclusion

Patients with non-traumatic headache as the primary presenting symptom in the ED are more oft women than men. The majority of headache patients in the ED had primary headaches with migraine being the most frequent diagnosis. Life threatening secondary headaches, including SAH and meningitis/encephalitis, were rare, bookkeeping for less than 2% of the patients. NSAIDs and acetaminophen were the most commonly used symptomatic therapy of headaches, while triptans were not used in the ED.

Availability of data and materials

The datasets analysed during the current report are available from the corresponding author on reasonable asking.

Abbreviations

CT:

Figurer Tomography

ECG:

Electrocardiogram

ED:

Emergency Department

ENT:

Ear-Olfactory organ-Throat

ICHD III:

International Classification of Headache Disorders, 3rd edition

MRI:

Magnet Resonance Imaging

Northward/A:

Non applicable

NSAIDs:

Non-steroidal-anti-inflammatory-Drugs

PGI:

Patients Global Impression,

SAH:

Subarachnoid haemorrhage

TACs:

Trigeminal autonomic cephalalgias

TTH:

Tension-type headache

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Acknowledgements

We wish to thank the patients participating in our inpatient assessment and treatment program. We are grateful to Salvatore Sarubb for performing statistical analyses.

Funding

There was no funding for the nowadays study.

Author information

Author notes

1. Alberto Doretti, Irina Shestaritc, Daniela Ungaro, John-Ih Lee, Loukas Lymperopoulos, Lili Kokoti, Martina Guglielmetti, Dimos Dimitrios Mitsikostas and Christian Lampl contributed equally to this work.

Affiliations

1. Department of Neurology-Stroke Unit of measurement and Laboratory of Neuroscience, Istituto Auxologico Italiano, Milan, Italy

   Alberto Doretti & Daniela Ungaro

2. Department of Neurorehabilitation, Yaroslavl regional clinical hospital of State of war Veterans, Yaroslavl, Russian federation

   Irina Shestaritc

3. Department of Neurology, Medical Kinesthesia, Heinrich-Heine-University, Duesseldorf, Germany

   John-Ih Lee

4. 80th Battalion of Medical Corps, General Ioannis Makrygiannis Camp, Pyli, Kos, Greece

   Loukas Lymperopoulos

5. General Hospital of Grevena, Grevena, Hellenic republic

   Lili Kokoti

6. Regional Referral Headache Centre, Sant' Andrea Infirmary, Rome, Italia

   Martina Guglielmetti

7. Department of Medical, Surgical and Experimental Sciences, University of Sassari, Rome, Italy

   Martina Guglielmetti

8. 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian Academy of Athens, Athens, Hellenic republic

   Dimos Dimitrios Mitsikostas

9. Headache Medical Center Linz, Ordensklinikum Barmherzige Schwestern, Seilerstaette 2-4, 4020, Linz, Republic of austria

   Christian Lampl

Consortia

on behalf of the Schoolhouse of Advanced Studies of the European Headache Federation (EHF-SAS)

Contributions

All Authors every bit contributed to the review. AD, IS, DU, J-IL, LL, LK, GF, MG are Junior Fellows of EHF-SAS. CL and DDM are Senior Fellows of EHF-SAS. All authors read and canonical the final manuscript.

Corresponding author

Correspondence to Christian Lampl.

Ethics declarations

Ethics approval and consent to participate

The report conformed to the revised ethical principles of the Helsinki announcement and the Codex rules and guidelines for enquiry. The present study is based on patients who participated in the inpatient assessment and handling program in the Emergency department San Luca Hospital of Istituto Auxologico Italiano, Milan, Italy and the Ordensklinikum Barmherzige Schwestern, Linz, Austria. During their kickoff date all patients participating in the survey provided written informed consent to use their information for the quality control, and to publish the data in anonymized form as function of the quality control process. Therefore, an ideals approval was not obtained for the present analysis.

Consent for publication

Written informed consent was obtained from the patient for the publication of this report.

Competing interests

The authors declare that they have no competing interests.

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Doretti, A., Shestaritc, I., Ungaro, D. et al. Headaches in the emergency section –a survey of patients' characteristics, facts and needs. J Headache Pain 20, 100 (2019). https://doi.org/10.1186/s10194-019-1053-five

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• Received: 08 July 2019

• Accepted: 13 Oct 2019

• Published: 05 November 2019

• DOI : https://doi.org/10.1186/s10194-019-1053-5

Keywords

• Headache
• Emergency department
• Primary headache
• Migraine
• Secondary headache

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