Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list

Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization

OBJECTIVES

The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk.

METHODS

We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods.

RESULTS

Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18-2.31) and 180 days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days.

CONCLUSIONS

Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.

SECONDARY NUMMULAR HEADACHE: A NEW CASE SERIES AND REVIEW OF THE LITERATURE

BACKGROUND

Nummular Headache (NH) is defined in the International Classification of Headache Disorders (ICHD) by the presence of localized pain circumscribed to a small round area of the scalp, not better accounted by any other diagnosis. As in many other primary headache disorders, secondary cases might occur. To date, 13 secondary cases have been published. We aim to present a long series of secondary NH and review the literature of symptomatic NH.

PATIENTS AND METHODS

Retrospective analysis of an observational prospective cohort in a headache unit located in a tertiary hospital. We included patients that fulfilled ICHD criteria and were attributed to a secondary cause. We describe the clinical characteristics, the underlying causes, and the response to treatment.

RESULTS

We included 274 NH patients, 8 of them (2.9%) were considered secondary. In 1 patient the underlying cause was subcutaneous, as for 6 cases the lesion was located in the bone (two hemangiomas, 1 osteoma, 3 different types of cysts), and in one was intracranial but closely related with internal diploe (cavernoma). Among our patients with secondary NH, a preventive therapy was not always needed and, when required, gabapentin or onabotulinumtoxinA were used with positive response.

CONCLUSION

Secondary NH phenotype overlaps primary NH. Therefore, we recommend routine imaging study in every NH patient. Concerning treatment, it was not necessary to remove the underlying lesion to control the pain and many cases responded to the same prophylactics as primary NH cases.

Navigating migraine care through the COVID-19 pandemic: an update

The worldwide treatment gap for migraine before COVID-19 inevitably widens as attention focuses on an international emergency. Migraine hits people particularly in their early and middle years, potentially reduces quality of life and productivity, and remains a common emergency presentation. This article examines the impact of COVID-19 on migraine, and changing aspects of migraine care during and after the pandemic. Many risk factors for severe COVID-19—older age, male gender, cardiac and respiratory diseases, diabetes, obesity, and immunosuppression—are less frequent in migraineurs. Telemedicine is effective for migraine follow-up, and needs ongoing evaluation. Most migraine treatments can start or continue in acute COVID-19, with care to avoid drug interactions. Close contact procedures (botulinum toxin, acupuncture and steroid injections) are avoided in lockdown or in the vulnerable. Secondary effects of COVID-19, including long COVID and its economic impact, are probably equal or greater in people with migraine. Migraine and other long-term conditions need adequate resourcing to prevent personal, social and economic suffering. Treating migraine, a sequel of COVID, potentially reduces the impact of long COVID.

Diagnosis and Management of Headache: A Review

IMPORTANCE

Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide.

OBSERVATIONS

Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo.

CONCLUSIONS AND RELEVANCE

Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department

Background: Headache is among the most prevalent complaints in patients presenting to the emergency department (ED). Clinicians are faced with the difficult task to differentiate primary (benign) from secondary headache disorders, since no international guidelines currently exist of clinical indicators for neuroimaging in headache patients.

Methods: We performed a retrospective review of 501 patients who presented at the ED with headache as a primary complaint between April 2018 and December 2018. Primary outcomes included the amount of diagnostic imaging, the different conclusions provided by diagnostic imaging, and the clinical factors associated with abnormal imaging results.

Results: About half of the patients were diagnosed with a primary headache disorder. Cranial CT imaging at the ED was performed regularly (61% of the patients) and led to the diagnosis of underlying pathology in 1 in 7.6 patients. In a multivariate model, factors significantly associated with abnormal cranial CT results were age 50 years or older, presentation within 1 h after headache onset, clinical history of aphasia, and focal neurological deficit at examination.

Conclusions: As separate clinical characteristics have limited value in detecting severe underlying headache disorders, cranial imaging is regularly performed in the ED. Clinical prediction model tools applied to headache patients may identify patients at risk of intracranial pathology prior to diagnostic imaging and reduce cranial imaging in the future.

Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 3rd edition, 2020

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.

Neurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics

PURPOSE OF REVIEW

Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia.

RECENT FINDINGS

Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.

Temporal distribution of emergency room visits in patients with migraine and other headaches

Background: Headache is a leading reason for presentation to the emergency department (ED) with migraine being the most frequently headache. To ensure the adequate staffing of healthcare providers during peak times of headache visits, we analyzed the temporal distribution of emergency department visits in patients presenting with headache and/or migraine.Research design and methods: The authors conducted an ecological study, including all consecutive visits to the ED for headache. Patients were classified according to the IHS Classification. We analyzed circadian, circaseptan and circannual patterns for number of visits, comparing migraine patients with other headache patients.Results: There were 2132 ED visits for headache, including primary headache in 1367 (64.1%) cases; migraine in 963 (45.2%); secondary headache in 404 (18.9%); and unspecified headache in 366 (17.1%). The circadian pattern showed peaks around 11:00-13:00 and 17:00-19:00, with visits during the night shift 45% less frequent (p < 0.001). The circaseptan pattern showed a peak on Monday-Tuesday and a low point on Sunday (p < 0.007). The circannual pattern peaked in March and decreased in June.Conclusions: ED visits for headache showed specific circadian, circaseptan and circannual variations. No differences were found in these patterns when comparing migraine patients to other headache patients.

Post-acute COVID-19 syndrome

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.

Tension-type headache

Tension-type headache (TTH) is the most prevalent neurological disorder worldwide and is characterized by recurrent headaches of mild to moderate intensity, bilateral location, pressing or tightening quality, and no aggravation by routine physical activity. Diagnosis is based on headache history and the exclusion of alternative diagnoses, with clinical criteria provided by the International Classification of Headache Disorders, third edition. Although the biological underpinnings remain unresolved, it seems likely that peripheral mechanisms are responsible for the genesis of pain in TTH, whereas central sensitization may be involved in transformation from episodic to chronic TTH. Pharmacological therapy is the mainstay of clinical management and can be divided into acute and preventive treatments. Simple analgesics have evidence-based effectiveness and are widely regarded as first-line medications for the acute treatment of TTH. Preventive treatment should be considered in individuals with frequent episodic and chronic TTH, and if simple analgesics are ineffective, poorly tolerated or contraindicated. Recommended preventive treatments include amitriptyline, venlafaxine and mirtazapine, as well as some selected non-pharmacological therapies. Despite the widespread prevalence and associated disability of TTH, little progress has been made since the early 2000s owing to a lack of attention and resource allocation by scientists, funding bodies and the pharmaceutical industry.

Need of guidance in disabling and chronic migraine identification in the primary care setting, results from the european MyLife anamnesis survey

Background

Migraine affects 80.8 million people in Western Europe and is the first cause of disability among people between ages 15 and 49 worldwide. Despite being a highly prevalent and disabling condition, migraine remains under-diagnosed and poorly managed.

Methods

An international, online survey was conducted among 201 general practitioners (GPs) from 5 European countries (France, Germany, Italy, Spain and the UK) who are experienced in the management of headache disorders.

Results

The majority of GPs (82%) did not refer patients with chronic migraine (CM) to migraine specialists. Among those patients, the participants estimated that around 55% received preventive medication. Some differences between countries were observed regarding referral rate and prescription of preventive treatment. Most GPs (87%) reported a lack of training or the need to be updated on CM management. Accordingly, 95% of GPs considered that a migraine anamnesis guide could be of use. Overall, more than 95% of GPs favoured the use of a patient diary, a validated diagnostic tool and a validated scale to assess impact of migraine on patients’ daily life. Similarly, 96% of the GPs considered that the inclusion of warning features (red flags) in an anamnesis guide would be useful and 90% favoured inclusion of referral recommendations.

Conclusions

The results from this survey indicate that more education on diagnosis and management of CM is needed in primary care. Better knowledge on the recognition and management of migraine in primary care would improve both prognosis and diagnosis and reduce impact of migraine on patients’ lives, healthcare utilization and societal burden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01402-2.

Cerebral venous thrombosis: Diagnosis and management in the emergency department setting

INTRODUCTION

Cerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes.

OBJECTIVE

This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician.

DISCUSSION

CVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases.

CONCLUSIONS

CVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.

Pediatric headache: Are the red flags misleading or prognostic?

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.

Management of thunderclap headache in the emergency room: A retrospective cohort study

INTRODUCTION

The evaluation of red flags is crucial for the accurate the diagnosis of headache disorders, especially for thunderclap headache. We analysed if secondary headache disorders were adequately ruled out in patients that presented to the emergency room with thunderclap headache.

METHODS

In this retrospective cohort study, we screened all patients that visited the emergency room for headache, including those that described thunderclap headache. We measured the frequency with which secondary causes were not adequately ruled out. We analysed the order of the exams, the final diagnosis, and the time elapsed between arrival, initial request for imaging, and the completion of the imaging.

RESULTS

We screened 2132 patients, and 42 (1.9%) fulfilled eligibility criteria. Mean age was 43.1 ± 17.1 years, and 57% of patients were female. For 22 (52.4%) patients, the work-up was incomplete. Vascular study was missing in 16 (38.1%) patients, cerebrospinal fluid evaluation in nine (21.4%), and magnetic resonance imaging in seven (16.7%), with multiple assessments missing in six (14.3%). There were ten different combinations in which the exams were performed, with the most frequent being the second exam's cerebral spinal fluid evaluation in 18 (52.9%) and the computed tomography angiogram in 10 (29.4%). A secondary cause of thunderclap headache was found in 16 (38.1%) patients, and four (9.5%) had a primary headache diagnosis after an adequate and complete study.

CONCLUSIONS

Thunderclap onset was described in one of every 50 patients that visited the emergency room for headache. More than half of these patients were not adequately managed. More than a third of thunderclap headache patients had a secondary cause.

Green Flags and headache: A concept study using the Delphi method

OBJECTIVE

The aim of this study was to collect and rate Green Flags, that is, symptoms or pieces of information indicating that a patient is more likely to suffer from a primary than from a secondary headache.

BACKGROUND

When assessing headaches, a central question to be answered is whether the pain is primary or secondary to another disorder. To maximize the likelihood of a correct diagnosis, relevant signs and symptoms must be sought, identified, and weighed against each other.

METHODS

The project was designed as a Delphi study. In the first round, an expert panel proposed green flags that were rated anonymously in two subsequent rounds. Proposals with an average rating of 4.0 and higher on a scale from 0 to 5 reached consensus.

RESULTS

Five Green Flags reached consensus: (i) "The current headache has already been present during childhood"; (ii) "The headache occurs in temporal relationship with the menstrual cycle"; (iii) "The patient has headache-free days"; (iv) "Close family members have the same headache phenotype"; and (v) "Headache occurred or stopped more than one week ago."

CONCLUSIONS

We propose five Green Flags for primary headache disorders. None being a pathognomonic sign, we recommend searching for both Green Flags and Red Flags. If both are present, a secondary headache should be suspected. Overall, the application of the Green Flag concept in clinical practice is likely to increase diagnostic accuracy and improve diagnostic resource allocation. Prospective studies in clinical populations should be conducted to validate these Green Flags.

Current clinical practice in disabling and chronic migraine in the primary care setting: results from the European My-LIFE anamnesis survey

Background

Migraine is a prevalent and disabling headache disorder that affects more than 1.04 billion individuals world-wide. It can result in reduction in quality of life, increased disability, and high socio-economic burden. Nevertheless, and despite the availability of evidence-based national and international guidelines, the management of migraine patients often remains suboptimal, especially for chronic migraine (CM) patients.

Methods

My-LIFE anamnesis project surveyed 201 General practitioners (GPs) from 5 European countries (France, Germany, Italy, Spain, and the UK) with the aim of understanding chronic migraine (CM) patients’ management in the primary care setting.

Results

In our survey, GPs diagnosed episodic migraine (EM) more often than CM (87% vs 61%, p < 0.001). We found that many CM patients were not properly managed or referred to specialists, in contrast to guidelines recommendations. The main tools used by primary-care physicians included clinical interview, anamnesis guide, and patient diary. Tools used at the first visit differed from those used at follow-up visits. Up to 82% of GPs reported being responsible for management of patients diagnosed with disabling or CM and did not refer them to a specialist. Even when the GP had reported referring CM patients to a specialist, 97% of them were responsible for their follow-up. Moreover, the treatment prescribed, both acute and preventive, was not in accordance with local and international recommendations. GPs reported that they evaluated the efficacy of the treatment prescribed mainly through patient perception, and the frequency of follow-up visits was not clearly established in the primary care setting. These results suggest that CM is underdiagnosed and undertreated; thereby its management is suboptimal in the primary care.

Conclusions

There is a need of guidance in the primary care setting to both leverage the management of CM patients and earlier referral to specialists, when appropriate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-02014-6.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers

BACKGROUND

Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting.

OBJECTIVE

The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment.

METHODS

The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed.

RESULTS

The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109).

CONCLUSION

Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

Headaches in Adults in Primary Care: Evaluation, Diagnosis, and Treatment

Headaches are common in primary care. The diagnosis is made by a careful history and physical examination. Imaging is generally not warranted. Several general principles underlie the acute treatment of headache: early initiation of therapy and adequate dosing at first dose. Careful attention to avoiding too frequent administration of acute therapy is important to avoid medication overuse headaches. Opioids should always be avoided. Preventive treatment is indicated for frequent headaches. Successful treatment entails low-dose medication with careful titration and monitoring of headache frequency. Behavioral strategies are important and should be part of any comprehensive headache management plan.

[COVID-19 and Headaches]

COVID-19 and Headaches Abstract. Headaches are a common symptom of COVID-19 infections. Patients generally describe them as bilateral, predominantly frontal, squeezing and of moderate or severe intensity. Searching for "Red Flags" often allows distinction from primary headaches - usually fever, cough, and elevated inflammatory markers accompany COVID-19-associated headaches. Prospective studies did not confirm caveats against the use of ibuprofen as symptomatic treatment. While carrying facial masks often caused headaches, probably by compressing sensory nerves, many patients' migraine frequencies dropped during lockdown. Treatment of patients with primary headaches was complicated by quarantine and many centres offered online consultations.

Migraine in Children Under 7 Years of Age: a Review

PURPOSE OF REVIEW

Despite the accumulation of a significant amount of data on pediatric headache, few studies have been conducted on its occurrence in children under 7 years of age. Within primary headaches in this age, migraine especially, turns out to be a disorder affecting up to 4% of the general population. An underestimate of its true prevalence can be due to lack of specific diagnostic markers, the frequent difficulty of describing pain in childhood, and the necessity of reliable parents' reports. Thus, migraine in children under 7 years of age represents an important challenge for clinicians. The objective of this manuscript is to provide a comprehensive review of epidemiologic, clinic, and therapeutic aspects of migraine in this age.

RECENT FINDINGS

Current literature data show that migraine has some differences, especially in clinical and therapeutic terms, in this age group compared to subsequent ages. Furthermore, some evidences showing that an early onset of migraine may play an unfavorable role in its natural history, suggest an early identification and management of migraine in younger children. Moreover, we highlight the role that factors of prenatal and perinatal development can play in the predisposition and anticipation of migraine onset. Finally, open questions related to the several undefined features of migraine in this age are reported. Migraine in this pediatric population is absolutely not rare, represents an importan clinical challenge and probably has a negative predictive role.

From first symptoms to diagnosis: Initial clinical presentation of primary brain tumors

Background:

Despite modern imaging methods, a long symptom-to-diagnosis interval can be observed in patients with primary brain tumors.

Objective:

The study evaluated the initial and subsequent clinical presentation of patients with brain tumors in the context of time to diagnosis, localization, histology, and tumor grading.

Methods:

In this retrospective analysis of 85 consecutive patients with primary brain tumors, we assessed the presenting symptoms and signs. The analyses were based on entries from medical records at the Department of Neurology of Zurich University Hospital between 2005 and 2010.

Results:

A total of 54 men and 31 women with a mean age at diagnosis of 48 years were included. 60% of the patients present with a malignant tumor (World Health Organization grading III–IV), 24.7% with a benign tumor (I–II), and 15.3% were not classified. The interval between symptom onset and diagnosis varied from 1 day to 96 months (median: 39 days). High-grade tumors (III–IV) were diagnosed significantly earlier than low-grade tumors (II) after the first symptoms occurred (median: 26 vs. 138 days; z = −3.847, p < 0.001).

Conclusions:

Symptoms with a short symptom-to-diagnosis interval such as nausea/vomiting, seizures, as well as of personality change are assumed to contribute to a faster diagnosis in high-grade tumors. Visual disturbances and headaches, although occurring relatively seldom, did not contribute to a decrease in time to diagnosis and should therefore be considered for further diagnostic workup.

Update on headache and brain tumors

Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis.

An unusual postural headache: a case report

BACKGROUND

This paper presents a case of an evolving unusual thunderclap headache that presented to a chiropractor.

CASE PRESENTATION

The intense "migraine-like" headache was aggravated by standing up and relieved substantially when lying down. This low pressure, orthostatic headache was diagnosed as a spontaneous intracranial hypotension (SIH) secondary to a spontaneous tear of the dura. It was referred to the local hospital for management with autogolous blood injection to form an epidural blood patch of the defect. It resolved substantially within 3 days.

CONCLUSIONS

The significance of key features in the history and examination and how if not recognised and subsequently treated with manual therapy, the dural tear could be attributed to the treatment of the chiropractor, a treatment that would typically involve cervical manipulation. Discussion is provided of the implications of a missed diagnosis and possible subsequent chiropractic management with the evolving SIH being attributed to the chiropractic intervention rather than its true "spontaneous" nature.

Phenotypic characterization of acute headache attributed to SARS-CoV-2: An ICHD-3 validation study on 106 hospitalized patients

Introduction

Headache is a common symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In this study, we aimed to characterize the phenotype of headache attributed to SARS-CoV-2 infection and to test the International Classification of Headache Disorders (ICHD-3) phenotypic criteria for migraine and tension-type headache.

Methods

The study design was a cross-sectional study nested in a cohort. We screened all consecutive patients that were hospitalized and had a positive SARS-CoV-2 test. We included patients that described headache if the headache was not better explained by another ICHD-3 diagnosis. Patients were interviewed by two neurologists.

Results

We screened 580 patients and included 130 (mean age 56 years, 64% female). Headache was the first symptom of the infection in 26% of patients and appeared within 24 hours in 62% of patients. The headache was bilateral in 85%, frontal in 83%, and with pressing quality in 75% of patients. Mean intensity was 7.1, being severe in 64%. Hypersensitivity to stimuli occurred in 57% of patients. ICHD-3 criteria for headache attributed to systemic viral infection were fulfilled by 94% of patients; phenotypic criteria for migraine were fulfilled by 25% of patients, and tension-type headache criteria by 54% of patients.

Conclusion

Headache attributed to SARS-CoV-2 infection in hospitalized patients has severe intensity, frontal predominance and oppressive quality. It occurs early in the course of the disease. Most patients fulfilled ICHD-3 criteria for headache attributed to systemic viral infection; however, the phenotype might resemble migraine in a quarter of cases and tension-type headache in half of the patients.

Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit

BACKGROUND

Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history.

METHODS

We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia.

RESULTS

A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia.

CONCLUSION

Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.

Hospital-based headache care during the Covid-19 pandemic in Denmark and Norway

Background

The Covid-19 pandemic is causing changes in delivery of medical care worldwide. It is not known how the management of headache patients was affected by the lockdown during the pandemic. The aim of the present study was to investigate how the initial phase of the Covid-19 pandemic affected the hospital management of headache in Denmark and Norway.

Methods

All neurological departments in Denmark (n = 14) and Norway (n = 18) were invited to a questionnaire survey. The study focused on the lockdown and all questions were answered in regard to the period between March 12th and April 15th, 2020.

Results

The responder rate was 91% (29/32). Of the neurological departments 86% changed their headache practice during the lockdown. The most common change was a shift to more telephone consultations (86%). Video consultations were offered by 45%.

The number of new headache referrals decreased. Only 36% administered botulinum toxin A treatment according to usual schemes. Sixty% reported that fewer patients were admitted for in-hospital emergency diagnostics and treatment. Among departments conducting headache research 57% had to halt ongoing projects. Overall, 54% reported that the standard of care was worse for headache patients during the pandemic.

Conclusion

Hospital-based headache care and research was impacted in Denmark and Norway during the initial phase of the Covid-19-pandemic.

Acute Treatment of Pediatric Migraine: A Review of the Updated Guidelines

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.

Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache

INTRODUCTION

Headache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache.

MATERIAL AND METHODS

We studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned.

RESULTS

We registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level.

CONCLUSION

During the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Headache in the neurology clinic: a 2-year audit

BACKGROUND

Headache is the most common reason for referral to neurology outpatient clinics in Ireland and represents approximately 30% of all new appointments.

AIM

To evaluate diagnoses and outcomes of all patients newly referred with headache to a consultant neurologist at an Irish university teaching hospital over a 2-year period.

DESIGN

A retrospective analysis and audit.

METHODS

Data including patient demographics, red flags, investigations, diagnosis, and outcome were collected on consecutive patients newly referred with headache to a consultant neurologist's outpatient clinic over a 2-year period.

RESULTS

Two hundred and seventy patients with headache were seen; 75% were women with mean age of 39 years. 89.26% (241/270) were diagnosed with a primary headache disorder alone; 4.44% (12/270) with a secondary headache disorder alone; 3.33% (9/270) with both a primary and secondary headache disorders; and 2.96% (8/270) with a painful cranial neuropathy. Migraine was the most common diagnosis, frequently associated with medication overuse. Non-attendance rates were high. Although imaging abnormalities were frequently found, on no occasion was it thought to be the cause of the headache.

CONCLUSIONS

Most patients referred to a neurology outpatient clinic with headache have a primary headache disorder. Alternate pathways should be considered to reduce the burden on Ireland's limited neurology resources without compromising patient safety.

Nummular Headache - a Case Report of a Rare Entity

PURPOSE OF REVIEW

The purpose of this manuscript is to shed light on systematic work-up of a diagnostic challenge such as nummular headache (NH), and to summarize the relevant literature on NH.

RECENT FINDINGS

The specific nature of the shape of the pain site is usually characteristic of NH. Multiple modalities of investigation including succinct imaging are necessary to successfully rule out other similar conditions. A 26-year-old female patient of Asian-Indian origin presented to the clinic with the chief complaint of chronic persistent left parietal headache for more than 10 years, which has been worsening over the past few days with no specific identifiable trigger. The diagnosis of nummular headache is challenging and confusing due to the rare occurrence and inadequate references in the literature. Appropriate imaging was done, which revealed no pathology that could explain the headache presentation. These findings are consistent with our diagnosis of nummular headache, and helped in the successful management of the case.

Employee and Employer Benefits From a Migraine Management Program: Disease Outcomes and Cost Analysis

OBJECTIVE

To assess the impact of a migraine management program offered as a complimentary service by a company within its corporate well-being program.

BACKGROUND

Migraine imposes a substantial burden on patients, families, employers, and societies. As migraine primarily affects working-age adults, this has important implications for both employees and employers. Workplace educational and well-being programs positively contribute to employees' productivity, reduce costs related to absenteeism, and improve the quality of life of the employees living with migraine.

METHODS

This was a non-interventional cohort study, which followed employees and their family members over time. Participants received 1 telemedicine consultation to determine migraine diagnosis or a high probability of having migraine and 6 sessions of individualized telecoaching from a specialized nurse via a specially developed smartphone application to optimize their migraine management leveraging all appropriate medical and lifestyle options. Participants were evaluated during the program and at 3 months after completion through a series of validated questionnaires including Migraine Disability Assessment (MIDAS), Patient Activation Measure (PAM), and satisfaction with the services offered. A cost analysis was also performed to determine the economic benefit of the program considering the number of completers, dropouts, their associated program costs, MIDAS data, average salary of a Swiss employee in the pharma sector, and working days per year.

RESULTS

Of the 141 participants enrolled in the program, 79 completed 6-month and 42 completed 9-month assessments. The total MIDAS scores (mean, standard deviation [SD]) significantly improved from baseline by 54% at Month 6 (15.0 [13.6] vs 6.9 [8.2]; mean [SD] reduction: 8.1 [12.9], 95% confidence interval [CI]: 5.6-10.6; P < .0001) and by 64% at Month 9 (15.4 [14.7] vs 5.6 [6.0]; mean [SD] reduction: 9.8 [14.0], 95% CI: 6.6-13.0; P < .0001). The PAM scores also significantly improved from baseline by 8% at Month 6 (63.8 [10.9] vs 69.6 [12.8]; mean [SD] increase: 5.8 [12.8], 95% CI: 3.2-8.4; P = .003) and 11% at Month 9 (63.5 [10.7] vs 71.3 [12.2]; mean [SD] increase: 7.8 [11.0], 95% CI: 4.3-11.2; P = .003). At Month 6, common coaching lessons and respective action plans focused on progressive muscle relaxation, sleep, hydration, nutrition, general disease education, and stress management. The exit survey showed that the majority of the participants who completed the program had a meaningful and sustained improvement in their overall health and reported a high level of satisfaction with the program. The cost analysis revealed that on average participants gained 10.8 (95% CI: 9.3-12.3) working days/year that were previously lost due to migraine, resulting in a positive return on investment (ROI) of 490% (95% CI: 410%-570%), indicating a higher magnitude of savings that could be achieved by the implementation of such program. In addition to ROI and work productivity gained, participants also gained on average 13.6 (95% CI: 9.9-17.3) migraine-free days/year for their private and social life.

CONCLUSION

The employer-sponsored disease management program provided a better understanding of migraine, promoted methods and approaches to improve management by combining medical and lifestyle options leading to significant improvements in migraine symptoms that sustained beyond the intervention, supporting prolonged effectiveness of such programs. The program also provided a high ROI to the employer, supporting that the systematic inclusion of such programs into corporate well-being initiatives can be of significant benefit not only to the impacted individuals but to the employers as well.

Frequency and Type of Red Flags in Patients With Covid-19 and Headache: A Series of 104 Hospitalized Patients

OBJECTIVE

In this study, we aimed to evaluate the frequency of the main red flags in patients with headache who do have Covid-19.

BACKGROUND

Headache is one of the most frequent neurologic symptoms of Coronavirus disease 2019 (Covid-19). Diagnosis of secondary headache disorders is still based on the presence of red flags.

DESIGN AND METHODS

Cross-sectional study of hospitalized patients with confirmed Covid-19 disease. We interrogated every patient about the presence of headache and if so, a headache expert conducted a structured interview assessing the presence and type of the main red flags. We evaluated the presence of laboratory abnormalities on admission.

RESULTS

We screened 576 consecutive patients, 130/576 (22.6%) described headache, and 104 were included in the study. Mean age of patients was 56.7 (standard deviation: 11.2) and 66/104 (63.4%) were female. Red flags concerning prior medical history were present in 79/104 (76.0%) cases, and those related to the headache itself were observed in 99/104 (95.2%) patients. All patients 104/104 (100%) described systemic symptoms and 86/104 (82.7%) some neurologic symptoms. Laboratory results were abnormal in 98/104 (94.2%) cases. The most frequent red flags were fever, in 93/104 (89.4%) patients, cough, in 89/104 (85.6% cases), and increased C-reactive protein in 84/100 (84.0%) cases.

CONCLUSION

In patients with Covid-19 that described the headache red flags were present in most cases. There was not any universal red flag, being necessary the comprehensive evaluation of all of them.

Presence of red flags in patients with cerebral venous sinus thrombosis admitted to the emergency department because of headache: A STROBE compliant cohort-study

Cerebral venous sinus thrombosis (CVST) is a cause of secondary headache with substantial morbimortality. Headache dominates the clinical presentation, but no typical phenotype has been described. We aim to evaluate the presence of red flags in headache in patients with confirmed CVST at the moment of emergency department (ED) presentation.Retrospective STROBE compliant cohort study including patients with confirmed CVST that consulted because of headache at the ED. We analyzed presence and type of red flags at the moment of consult. We evaluated whether CVST was suspected at the moment of imaging request and analyzed delay in the diagnosis.Nineteen patients fulfilled inclusion and exclusion criteria. Mean age was 48.5 years, 47.4% were female. All the studied patients exhibited at least 1 red flag, being abnormal neurological examination the most frequent (79%), followed by the presence of other neurological symptoms (68%), alarm data related with headache phenotype (63%), or risk factors concerning prior medical history (47%). Temporal pattern of the headache was acute in 42.1%, thunderclap in 31.6%, and subacute in 26.3%. In none patient CVST was the specific suspicion when imaging was requested. Median time since headache onset and ED presentation was 84 hours, being different in patients with associated symptoms (48 hours) when compared with isolated headache patients (168 hours). Time since ED presentation and the diagnosis also differed between the 2 groups, being more prolonged in patients with an isolated headache at presentation.Headache attributed with CVST did not exhibit any distinctive phenotype, but all the patients presented some red flag, being abnormal neurological examination the most frequent.

Autoimmune glial fibrillary acidic protein astrocytopathy mimics infectious meningitis: Two case reports

BACKGROUND

Autoimmune glial fibrillary acidic protein astrocytopathy (A-GFAP-A) has been recently characterized as a novel autoimmune central nervous system (CNS) disorder with GFAP antibody as the biomarker. However, nonspecific symptoms of A-GFAP-A contribute to misdiagnosis.

CASE PRESENTATION

The patients presented with initial symptoms of fever, headache, and nuchal rigidity. Case 1 exhibited mild signs of irritability, active tendon reflexes, and dysuria; case 2 had transient loss of consciousness. Cerebrospinal fluid (CSF) revealed lymphocytosis, elevated protein level, and decreased glucose level. Magnetic resonance imaging (MRI) revealed radial gadolinium enhancement perpendicular to the lateral ventricle. Viral meningitis or tubercular meningitis was suspected. However, their inflammatory and pathogenic indicators showed no abnormal changes, and empirical antibiotic and antiviral drugs did not result in remarkable recovery. Subsequently, cases were detected with a strongly positive expression of GFAP antibody in CSF and the symptoms improved dramatically after high-dose methylprednisolone pulse treatment.

CONCLUSION

A-GFAP-A with meningitis-like symptoms could initially masquerade as intracranial infection, and prompt detection of GFAP antibody is essential for differentiation.

Low-value care practice in headache: a Spanish mixed methods research study

BACKGROUND

Headache is one of the most prevalent diseases. The Global Burden of Disease Study ranks it as the seventh most common disease overall and the second largest neurological cause of disability in the world. The "Do Not Do" recommendations are a strategy for increasing the quality of care and reducing the cost of care for headache. This study aimed to identify specific low-value practices in headache care, determine their frequency, and estimate the cost overrun that they represent, in order to establish "Do not Do" recommendations specifically for headache by consensus and according to scientific evidence.

METHODS

This was a mixed methods research study that combined qualitative consensus-building techniques, involving a multidisciplinary panel of experts to define the "Do Not Do" recommendations in headache care, and a retrospective observational study with review of a randomized set of patient records from the past 6 months in four hospitals, to quantify the frequency of these "Do Not Do" practices. We calculated the sum of direct costs of medical consultations, medicines, and unnecessary diagnostic tests.

RESULTS

Seven "Do Not Do" recommendations were established for headache. In total, 3507 medical records were randomly reviewed. Low-value practices had a highly variable occurrence, depending on the hospital and type of headache. Overall, 34.1% of low-value practices were related to treatment, 21% were related to overuse of imaging in consultation, and 19% were related to emergency care. The estimated cost of low-value practices in the four hospitals was 203,520.47 euros per 1000 patients.

CONCLUSIONS

This study identified low-value headache practices that need to be eradicated and provided data on their frequency and cost overruns.

Retrospective Review of Pregnant Patients Presenting for Evaluation of Acute Neurologic Complaints

STUDY OBJECTIVE

Data suggest an increase in neurologic-related hospitalizations during pregnancy. It is crucial for health care providers to develop effective strategies to evaluate this young, generally healthy cohort of patients for whom missed neurologic diagnoses can have devastating results. We aim to describe the epidemiology of this high risk patient population by investigating exam findings, imaging studies, and clinical outcomes of pregnant women presenting to the emergency department (ED) with acute neurologic complaints.

METHODS

We conducted a 7-year retrospective chart review of pregnant patients presenting with neurologic chief complaints to the emergency department of an urban tertiary academic medical center in the northeastern United States. We investigated examination findings, imaging studies, and clinical outcomes.

RESULTS

Between January 1, 2010, and May 31, 2017, 205 pregnant patients presented to the ED with a neurologic chief complaint. The majority of patients had a normal neurologic examination result. Patients with an abnormal examination result were not more likely to have clinically significant imaging findings. Within our population, 28% underwent imaging, and noncontrast magnetic resonance imaging was the most common modality. Five patients had clinically significant imaging findings. Specifically, 3.3% of patients with abnormal examination result had significant findings and 2.3% of those with a normal examination result had significant findings. A minority of the patients with a visit resulting in discharge (9.8%) returned to the ED within a 7-day period. None required additional neuroimaging.

CONCLUSION

To our knowledge, our study is unique in that it incorporated all neurologic complaints. Headache was the most common complaint, followed by dizziness and seizures. Most of the headaches were related to first-trimester migraines. There was a high incidence of imaging used in clinical practice even when there was a normal neurologic examination result. A normal examination result does not adequately exclude serious intracranial pathology, and diagnostic vigilance is justified.

Assessing diagnostic error in cerebral venous thrombosis via detailed chart review

Background Diagnostic error in cerebral venous thrombosis (CVT) has been understudied despite the harm associated with misdiagnosis of other cerebrovascular diseases as well as the known challenges of evaluating non-specific neurological symptoms in clinical practice. Methods We conducted a retrospective cohort study of CVT patients hospitalized at a single center. Two independent reviewers used a medical record review tool, the Safer Dx Instrument, to identify diagnostic errors. Demographic and clinical factors were abstracted. We compared subjects with and without a diagnostic error using the t-test for continuous variables and the chi-square (χ2) test or Fisher's exact test for categorical variables; an alpha of 0.05 was the cutoff for significance. Results A total of 72 CVT patients initially met study inclusion criteria; 19 were excluded due to incomplete medical records. Of the 53 patients included in the final analysis, the mean age was 48 years and 32 (60.4%) were women. Diagnostic error occurred in 11 cases [20.8%; 95% confidence interval (CI) 11.8-33.6%]. Subjects with diagnostic errors were younger (42 vs. 49 years, p = 0.13), more often women (81.8% vs. 54.8%, p = 0.17), and were significantly more likely to have a past medical history of a headache disorder prior to the index CVT visit (7.1% vs. 36.4%, p = 0.03). Conclusions Nearly one in five patients with complete medical records experienced a diagnostic error. Prior history of headache was the only evaluated clinical factor that was more common among those with an error in diagnosis. Future work on distinguishing primary from secondary headaches to improve diagnostic accuracy in acute neurological disease is warranted.

The Many Faces of Medication-Overuse Headache in Clinical Practice

The management of medication-overuse headache (MOH) is multifaceted and headache experts have different views on the optimal strategy to tackle this type of secondary headache. The purpose of this review is to provide an overview of the literature on the management of MOH, and to highlight important considerations in the clinical evaluation of the MOH patient. Managing MOH in clinical practice starts by evaluating the headache patient with medication overuse, determining the overused drug(s), assessing the impact of headaches on the patient and assessing comorbid conditions and disorders. Withdrawal of the overused medication is the cornerstone of treatment. An inpatient or outpatient setting is chosen based on the clinical profile of the patient. There is evidence for abrupt withdrawal combined with headache preventive treatment. Bridging therapy to bring relief to withdrawal headaches and/or symptoms should be offered. Education and motivational work through multidisciplinary assessment show benefits in sustaining withdrawal and preventing relapse. Although the reversal of chronic headache after cessation of overused acute medication has been noticed worldwide, different aspects of the management of MOH, such as complete or gradual withdrawal, or preventive treatment with or without withdrawal are still debated.

Tension-type headache in the Emergency Department Diagnosis and misdiagnosis: The TEDDi study

Headache is a common reason to visit the emergency department (ED). Tension-type headache (TTH) is the commonest headache. The diagnosis of TTH implies a mild condition, with no need for special tests. We evaluated the use of the International Classification of Headache Disorders (ICHD) criteria for TTH in the ED. We performed a cross-sectional study including all ED patients with a definite TTH diagnosis in their discharge report for 2.5 years. We evaluated whether the ICHD criteria for TTH were referenced and met. We analysed discrepancies concerning anamnesis or prior history and reclassified patients. A total of 211 out of 2132 patients fulfilled the criteria (9.9%). Only five patients fulfilled TTH criteria. Criteria A-D were referenced in 60-84% of patients and met in 16-74% of these patients. Anamnesis was discrepant in 87.5% as was prior history in 20.8%. After re-reclassification, 21 patients fulfilled the criteria for TTH (five) or probable TTH (16). In 106 patients, another headache was diagnosed, with migraine in 40 (18.9%), secondary headache in 64 (30.3%), and a life-threatening disorder in 13 (6.1%). In our sample, TTH was overdiagnosed. Only a minority of patients fulfilled the ICHD criteria. Inconsistencies in prior medical history or anamnesis were frequent.

Headache and Methemoglobinemia

AIM

This basic review is intended to summarize the current knowledge of methemoglobinemia as an important cause of secondary headache with the hope of generating a growing interest in studying this phenomenon.

BACKGROUND

We describe the pathological underpinnings of headaches generated by hypoxia. Possible mechanisms include cerebral vasodilation-associated stretching of the vessel nociceptors, sensitization of perivascular nociceptors mediated by nitric oxide, cerebral calcitonin gene-related peptide, activation of the cyclic adenosine monophosphate pathway, cortical spreading depression, disruption of the blood-brain barrier, and neurogenic inflammation. We review the clinical features, pathophysiology, and management of methemoglobinemia. We conducted a literature review of reports of symptomatic methemoglobinemia with headache. In addition, we describe a case report of a patient who presented with an acute onset of severe holocranial headache associated with rapidly progressive perioral paresthesia, cyanosis in lips and hands, nausea, and mild dyspnea on exertion. These features can be misinterpreted as an acute attack of migraine with pain-related hyperventilation syndrome and anxiety leading to clinically detrimental delay in the management of the progressive hypoxia. Her symptoms resolved following treatment with methylene blue. The complex relationship of migraine and hypoxia-related headaches is also reviewed. We propose that methemoglobinemia-associated headaches are possibly generated by stretching of the nociceptor nerve endings during cerebral vasodilation and hypoxia-mediated oxidative stress.

CONCLUSIONS

The case highlights the need to broaden the formulated differential diagnosis of an acute onset severe holocranial headache and pay careful attention to other signs and symptoms that may provide hints on potential mechanism(s) for secondary headaches. We provide justification for the need to incorporate "Headache attributed to Methemoglobinemia" as a subtype under the section "Headache attributed to hypoxia and/or hypercapnia" of the International Classification of Headache Disorders to support clinical decision making.

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

Background and aim

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

Methods

This retrospective survey was performed from September 2018 until January 2019. Patients were collected from the San Luca Hospital, Milan, Italy and the Ordensklinikum Barmherzige Schwestern, Linz, Austria. Only patients with a non-traumatic headache, as the primary reason for medical clarification, were included. Patients were analysed for their complexity and range of examination, 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. Technical investigation was performed in 57.8% of patients. For acute treatment non-steroidal-anti-inflammatory drugs (NSAIDs) were the most used, whereas triptans were not given. A primary headache disorder was diagnosed in 45.3% of patients, being migraine the most common, but in 32% of cases the diagnosis was not 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 primary headache disorder. Life-threatening secondary headaches are rare but seek attention. NSAIDs are by far the most common drugs for treating headaches in the ED, but not triptans.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort

BACKGROUND AND PURPOSE

Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs.

METHODS

This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments.

RESULTS

In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication.

CONCLUSIONS

Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.