Undertreatment in patients with primary headaches attending headache centres

Systematic literature review on the delays in the diagnosis and misdiagnosis of cluster headache

INTRODUCTION

Patients with cluster headache (CH), the most common trigeminal autonomic cephalalgia, often face delayed diagnosis, misdiagnosis and mismanagement.

OBJECTIVES

To identify, appraise and synthesise clinical studies on the delays in diagnosis and misdiagnosis of CH in order to determine its causes and help the management of this condition.

METHODS

The systematic review was prepared, conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis. It was registered with International Prospective Register of Systematic Reviews. A systematic search of different electronic databases (Medline, EMBASE, PsycINFO, PubMed, CINAHL, BNI, HMIC, AMED, HBE and Cochrane Library) was carried out in May 2017. Reference lists of relevant articles were hand searched.

RESULTS

The search identified 201 unique studies. Fifteen studies met the inclusion criteria of which 13 case series studies and two survey studies. Nine studies assessed the delays in diagnosis and misdiagnosis of CH, five studies the delays in diagnosis and one study the misdiagnosis of CH. The studies included 4661 patients. Delays in diagnosis, misdiagnosis and mismanagement have been reported in many European countries, Japan and in the USA with well-developed health services. The patients with CH often visited many different clinicians, surgeons and dentists and received multiple diagnosis prior to being correctly diagnosed.

CONCLUSION

This systematic review shows that the delays in the diagnosis of CH are a widespread problem, the time to diagnosis still vary from country to country and both patients and physicians are responsible for the delays in diagnosis.

Medication usage patterns for headache treatment after mild traumatic brain injury

OBJECTIVE

To describe patient self-report of headache treatment in the first year following mild traumatic brain injury (TBI).

BACKGROUND

An understanding of appropriate management of symptoms after mild TBI is crucial for improving acute care and long-term outcomes. This is particularly true for post-traumatic headaches as recent studies suggest that headaches after mild TBI are common with multiple phenotypes. In addition, symptoms such as headache after mild TBI are often managed by primary care providers without specialty training, and often in medically underserved areas. Outside of previous opinion papers, few studies have guided the treatment or examined the effectiveness of the interventions for post-traumatic headache.

METHODS

One hundred sixty-seven participants admitted to a level 1 trauma hospital with mild TBI who were prospectively enrolled and reported new or worse headache at 3, 6, or 12 months after injury.

RESULTS

Participants were primarily male (75%), white (75%), injured in vehicle crashes (62%), and had completed high school (83%). The majority of headaches met International Classification of Headache Disorders-2nd edition criteria for migraine/probable migraine, followed by tension-type headache. Despite the diverse nature of headaches, more than 70% of those with headache at each time period used acetaminophen or a nonsteroidal anti-inflammatory drug for headache control. Only 8% of those with the migraine/probable migraine phenotype used triptans. Of those individuals who used medication, 26% of those with migraine/probable migraine phenotype and 70% of those with tension headache phenotype endorsed complete relief (vs partial or no relief) because of medication use. The majority of individuals with tension headache reported never taking medication.

CONCLUSIONS

Headaches after mild TBI are frequent and are not optimally treated. Results suggest that many individuals with mild TBI may be self-treating their headaches by utilizing over-the-counter pain relief medications. These medications, however, are only providing effective treatment for a minority of this population. Further research must be conducted to develop evidence-guided treatment and educate providers.