1
|
Evan JR. Approach to the Diagnosis and Treatment of Headache. Prim Care 2024; 51:179-193. [PMID: 38692769 DOI: 10.1016/j.pop.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Headache is consistently one of the most common complaints reported by patients in the medical setting worldwide. Headache can be a symptom of another condition or illness, secondary to the disruption of homeostasis, or can be a primary disorder with inherent variability and patterns. Headache disorders, whether primary or secondary, can cause significant disability and loss of quality of life for those affected. As such, it is important for primary care providers to feel confident evaluating and treating patients with headache, especially given the limited access to Headache Medicine subspecialists.
Collapse
Affiliation(s)
- Jennifer R Evan
- Department of Neurology, University of Colorado School of Medicine, Anschutz Medical Campus, 12469 East 17th Place Mail Stop F429, Aurora, CO 80045, USA; Jesse Brown Veterans Affairs Medical Center, Headache Center of Excellence 820 S Damen Avenue, Chicago, IL 60612.
| |
Collapse
|
2
|
Chu K, Kelly AM, Kuan WS, Kinnear FB, Keijzers G, Horner D, Laribi S, Cardozo A, Karamercan MA, Klim S, Wijeratne T, Kamona S, Graham CA, Body R, Roberts T. Predictive performance of the common red flags in emergency department headache patients: a HEAD and HEAD-Colombia study. Emerg Med J 2024; 41:368-375. [PMID: 38658053 DOI: 10.1136/emermed-2023-213461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Only a small proportion of patients presenting to an ED with headache have a serious cause. The SNNOOP10 criteria, which incorporates red and orange flags for serious causes, has been proposed but not well studied. This project aims to compare the proportion of patients with 10 commonly accepted red flag criteria (singly and in combination) between patients with and without a diagnosis of serious secondary headache in a large, multinational cohort of ED patients presenting with headache. METHODS Secondary analysis of data obtained in the HEAD and HEAD-Colombia studies. The outcome of interest was serious secondary headache. The predictive performance of 10 red flag criteria from the SNNOOP10 criteria list was estimated individually and in combination. RESULTS 5293 patients were included, of whom 6.1% (95% CI 5.5% to 6.8%) had a defined serious cause identified. New neurological deficit, history of neoplasm, older age (>50 years) and recent head trauma (2-7 days prior) were independent predictors of a serious secondary headache diagnosis. After adjusting for other predictors, sudden onset, onset during exertion, pregnancy and immune suppression were not associated with a serious headache diagnosis. The combined sensitivity of the red flag criteria overall was 96.5% (95% CI 93.2% to 98.3%) but specificity was low, 5.1% (95% CI 4.3% to 6.0%). Positive predictive value was 9.3% (95% CI 8.2% to 10.5%) with negative predictive value of 93.5% (95% CI 87.6% to 96.8%). CONCLUSION The sensitivity and specificity of the red flag criteria in this study were lower than previously reported. Regarding clinical practice, this suggests that red flag criteria may be useful to identify patients at higher risk of a serious secondary headache cause, but their low specificity could result in increased rates of CT scanning. TRIAL REGISTRATION NUMBER ANZCTR376695.
Collapse
Affiliation(s)
- Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Footscray, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, Singapore
| | - Frances B Kinnear
- Emergency and Children's Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France
| | | | | | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Footscray, Victoria, Australia
| | - Tissa Wijeratne
- Department of Neurology, Western Health, Footscray, Victoria, Australia
| | - Sinan Kamona
- School of Medicine, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Colin A Graham
- Emergency Medicine, Chinese University of Hong Kong - Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Richard Body
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Tom Roberts
- Trainee Emergency Research Network, London, UK
- North Bristol NHS Trust, Bristol, UK
| |
Collapse
|
3
|
Cappellari AM, Bruschi G, Beretta GB, Molisso MT, Bertolozzi G. How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department? CHILDREN (BASEL, SWITZERLAND) 2023; 10:1837. [PMID: 38136039 PMCID: PMC10742139 DOI: 10.3390/children10121837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.
Collapse
Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gaia Bruschi
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Gisella B. Beretta
- Postgraduate School of Paediatrics, Università degli Studi di Milano, 20122 Milan, Italy; (G.B.); (G.B.B.)
| | - Maria T. Molisso
- Department of Neuroscience and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Giuseppe Bertolozzi
- Pediatric Emergency Department, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| |
Collapse
|
4
|
Chu K, Kelly AM, Keijzers G, Kinnear F, Kuan WS, Graham C, Laribi S, Roberts T, Karamercan M, Cardozo-Ocampo A, Kamona S, Body R, Horner D, Klim S, Brown N, Wijeratne T. Computed tomography brain scan utilization in patients with headache presenting to emergency departments: a multinational study. Eur J Emerg Med 2023; 30:356-364. [PMID: 37310953 DOI: 10.1097/mej.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND IMPORTANCE Recommended indications for emergency computed tomography (CT) brain scans are not only complex and evolving, but it is also unknown whether they are being followed in emergency departments (EDs). OBJECTIVE To determine the CT utilization and diagnostic yield in the ED in patients with headaches across broad geographical regions. DESIGN Secondary analysis of data from a multinational cross-sectional study of ED headache presentations over one month in 2019. SETTING AND PARTICIPANTS Hospitals from 10 participating countries were divided into five geographical regions [Australia and New Zealand (ANZ); Colombia; Europe: Belgium, France, UK, and Romania; Hong Kong and Singapore (HKS); and Turkey). Adult patients with nontraumatic headache as the primary presenting complaint were included. Patients were identified from ED management systems. OUTCOME MEASURES AND ANALYSIS The outcome measures were CT utilization and diagnostic yield. CT utilization was calculated using a multilevel binary logistic regression model to account for clustering of patients within hospitals and regions. Imaging data (CT requests and reports) were sourced from radiology management systems. MAIN RESULTS The study included 5281 participants. Median (interquartile range) age was 40 (29-55) years, 66% were women. Overall mean CT utilization was 38.5% [95% confidence interval (CI), 30.4-47.4%]. Regional utilization was highest in Europe (46.0%) and lowest in Turkey (28.9%), with HKS (38.0%), ANZ (40.0%), and Colombia (40.8%) in between. Its distribution across hospitals was approximately symmetrical. There was greater variation in CT utilization between hospitals within a region than between regions (hospital variance 0.422, region variance 0.100). Overall mean CT diagnostic yield was 9.9% (95% CI, 8.7-11.3%). Its distribution across hospitals was positively skewed. Regional yield was lower in Europe (5.4%) than in other regions: Colombia (9.1%), HKS (9.7%), Turkey (10.6%), and ANZ (11.2%). There was a weak negative correlation between utilization and diagnostic yield ( r = -0.248). CONCLUSION In this international study, there was a high variation (28.9-46.6%) in CT utilization and diagnostic yield (5.4-11.2%) across broad geographic regions. Europe had the highest utilization and the lowest yield. The study findings provide a foundation to address variation in neuroimaging in ED headache presentations.
Collapse
Affiliation(s)
- Kevin Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast
- School of Medicine, Bond University, Gold Coast
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | | | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Colin Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Said Laribi
- Department of Emergency Medicine, Tours University Hospital, Tours, France
| | - Tom Roberts
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Mehmet Karamercan
- Department of Emergency Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | | | - Sinan Kamona
- Adult Emergency Department, Auckland City Hospital
- Faculty of Health and Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Richard Body
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust
- Division of Cardiovascular Science, University of Manchester, Manchester
| | - Daniel Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research, Western Health, Melbourne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - Nathan Brown
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Brisbane
- Faculty of Medicine, University of Queensland, Queensland
| | - Tissa Wijeratne
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Tana C, Azorin DG, Cinetto F, Mantini C, Tana M, Caulo M, Ricci F, Martelletti P, Cipollone F, Giamberardino MA. Common Clinical and Molecular Pathways between Migraine and Sarcoidosis. Int J Mol Sci 2023; 24:ijms24098304. [PMID: 37176011 PMCID: PMC10179000 DOI: 10.3390/ijms24098304] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/07/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Migraine and sarcoidosis are two distinct medical conditions that may have some common biological and clinical pathways. Sarcoidosis is a chronic granulomatous disease characterized by the formation of granulomas in various organs, including the lungs, skin, cardiovascular system, lymph nodes, and brain. Migraine is a common comorbidity in sarcoidosis patients and a common neurological disorder characterized by recurrent headaches that can be accompanied by other symptoms, such as nausea, vomiting, and sensitivity to light and sound. There have been several reports of individuals with neurosarcoidosis experiencing migraines, though the exact relationship between the two disorders is not well understood. Both conditions have been associated with inflammation and the activation of the immune system. In sarcoidosis, the formation of granulomas is thought to be an immune response to the presence of an unknown antigen. Similarly, the pain and other symptoms associated with migraines are thought to be caused by inflammation in the brain and the surrounding blood vessels. There is also evidence to suggest an interplay of environmental and genetic factors playing a role in both conditions, but evidence is inconsistent with the hypothesis of shared genetic susceptibility. This review aims to illustrate common clinical and biological pathways between migraine and sarcoidosis, including inflammation and dysregulation of the immune system, with a focus on the cumulative burden of concurrent disorders and therapeutic implications.
Collapse
Affiliation(s)
- Claudio Tana
- Center of Excellence on Headache, Geriatrics and COVID-19 Clinic, SS Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - David Garcia Azorin
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Francesco Cinetto
- Rare Diseases Referral Center, Internal Medicine 1, Ca' Foncello Hospital-AULSS2 Marca Trevigiana and Department of Medicine-DIMED, University of Padova, 35122 Padova, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marco Tana
- 2nd Internal Medicine Unit, SS. Medical Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
- University Cardiology Division, Heart Department, SS. Annunziata Hospital of Chieti, 66100 Chieti, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Francesco Cipollone
- Medical Clinic, Department of Medicine and Science of Aging, SS. Annunziata Hospital of Chieti, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy
| | - Maria Adele Giamberardino
- Center of Excellence on Headache, Geriatrics and COVID-19 Clinic, SS Annunziata Hospital of Chieti, 66100 Chieti, Italy
| |
Collapse
|