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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:emermed-2023-213461. [PMID: 38658053 DOI: 10.1136/emermed-2023-213461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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.
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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
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Ajhar A, Kothakapu R, Arends M, Anderson M, Scott SE. Persistent headache without neurologic deficit from a spontaneous vertebral artery dissection: A case report. Am J Emerg Med 2024:S0735-6757(24)00158-X. [PMID: 38658200 DOI: 10.1016/j.ajem.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/25/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Non-traumatic headache is a common complaint seen in the emergency department (ED), accounting for 2.3% of ED visits per year in the United States (Munoz-Ceron et al., 2019). When approaching the workup and management of headache, an emergency medicine physician is tasked with generating a deadly differential by means of a thorough history and physical exam to determine the next best steps. CASE A 21-year-old male presented to the emergency department with a debilitating new-onset headache, preceded by an isolated vertiginous event 3 days prior. He was found to have a normal neurologic examination. A non-contrast CT scan of the head revealed a large hypodensity within the left cerebellum with a subsequent MRA of the brain and neck notable for a left vertebral artery dissection, complicated by an ischemic cerebellar stroke. DISCUSSION With an estimated incidence of 1-5 per 100,000, vertebral artery dissection is a rare cause of stroke within the general population and carries with it a high degree of morbidity and mortality (Rodallec et al., 2008). Vertebral artery dissection is a result of blood penetrating the intimal wall of the artery to form an intramural hematoma. Diagnosis can be difficult in cases presenting subacutely but a thorough history evaluating for red flags and using simple but highly sensitive exams such as the bedside HINTS exam can increase pretest probability of stroke. Clinical syndromes, red flags, and time from onset of symptoms should guide imaging modalities such as CT, CTA, MRI, and MRA in detection of small ischemic changes, intimal flaps, and luminal thromboses. CONCLUSION Vertebral artery dissection should remain high on the differential for an emergency medicine physician when history is suggestive of a new onset headache, preceded by vertiginous symptoms. An absence of recent trauma and a normal neurologic examination does not eliminate the diagnosis.
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Affiliation(s)
- Alec Ajhar
- Emergency Medicine Resident at Madigan Army Medical Center, 9040A Jackson Avenue Joint Base Lewis-McChord, WA 98431-1100, USA.
| | - Rohith Kothakapu
- Neurology Resident at Madigan Army Medical Center, 9040A Jackson Avenue Joint Base Lewis-McChord, WA 98431-1100, USA.
| | - Mitchell Arends
- Emergency Medicine Resident at Madigan Army Medical Center, 9040A Jackson Avenue Joint Base Lewis-McChord, WA 98431-1100, USA.
| | - Matthew Anderson
- Neurology Resident at Madigan Army Medical Center, 9040A Jackson Avenue Joint Base Lewis-McChord, WA 98431-1100, USA.
| | - Sean E Scott
- Attending Physician at Madigan Army Medical Center, 9040A Jackson Avenue Joint Base Lewis-McChord, WA 98431-1100, USA.
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Tana C, Raffaelli B, Souza MNP, de la Torre ER, Massi DG, Kisani N, García-Azorín D, Waliszewska-Prosół M. Health equity, care access and quality in headache - part 1. J Headache Pain 2024; 25:12. [PMID: 38281917 PMCID: PMC10823691 DOI: 10.1186/s10194-024-01712-7] [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: 12/01/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
Current definitions of migraine that are based mainly on clinical characteristics do not account for other patient's features such as those related to an impaired quality of life, due to loss of social life and productivity, and the differences related to the geographical distribution of the disease and cultural misconceptions which tend to underestimate migraine as a psychosocial rather than neurobiological disorder.Global differences definition, care access, and health equity for headache disorders, especially migraine are reported in this paper from a collaborative group of the editorial board members of the Journal of Headache and Pain. Other components that affect patients with migraine, in addition to the impact promoted by the migraine symptoms such as stigma and social determinants, are also reported.
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Affiliation(s)
- Claudio Tana
- Center of Excellence on Headache and Geriatrics Clinic, SS Annunziata Hospital of Chieti, Chieti, Italy.
| | - Bianca Raffaelli
- Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Berlin, Germany
| | | | | | - Daniel Gams Massi
- Neurology Unit, Douala General Hospital, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Najib Kisani
- Department of Neurology, Mohammed VI University Hospital, Marrakech, Morocco
| | - David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, 47003, Valladolid, Spain
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Vajdi M, Khorvash F, Rouhani MH, Ghavami A, Clark CCT, Askari G. Effect of inulin supplementation on clinical symptoms, inflammatory and oxidative stress markers in women with migraine: study protocol for a randomized clinical trial. Trials 2023; 24:722. [PMID: 37951975 PMCID: PMC10640733 DOI: 10.1186/s13063-023-07765-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Migraine is a complex, chronic, and debilitating multifactorial disorder characterized by recurrent episodes of headache and related symptoms. It typically begins in early ages and is more prevalent in women than in men. Recently, the gut-brain axis has emerged as a new candidate that may be linked to neurological diseases. We hypothesize that selective modulation of the intestinal microbiota, oxidative stress, and inflammation through inulin supplementation may improve clinical outcomes in these patients. Therefore, this study aims to examine the effects of high-performance inulin supplementation on clinical symptoms, mental health, quality of life (QOL), intestinal permeability, and inflammatory and oxidative stress factors in women with migraine. METHODS This is a randomized, double-blind, placebo-controlled clinical trial involving 80 women with migraine who meet the inclusion criteria (aged between 20 and 50 years with a diagnosis of migraine by a neurologist based on the ICDH-3). Participants will be assigned to receive a daily dose of 10 g of inulin for 12 weeks (intervention group, n = 40) or 10 g of maltodextrin as a placebo for the same duration (control group, n = 40). The primary outcome will measure the variations in the frequency of headache experienced by the patients. Secondary outcomes will encompass serum levels of zonulin, high-sensitive C-reactive protein, total antioxidant capacity, total oxidant status, nitric oxide, mental status, QOL, duration, and severity of migraine attacks. DISCUSSION This clinical trial aims to evaluate the effect of inulin supplementation on inflammatory status, oxidative stress, intestinal permeability, clinical symptoms, mental health, and QOL in women with migraine. The findings of this trial could contribute to the identification of mechanistic action and evidence-based clinical guidelines that address gut microbiota manipulation to maximize health benefits in the management of clinical outcomes in migraine patients. TRIAL REGISTRATION Iranian Registry of Clinical Trials ( www.irct.ir ) (ID: IRCT20121216011763N58). Registration date: 23 April 2023. TRIAL STATUS The protocol is version 3.0, September 17, 2023. Recruitment began August 21, 2023, and is anticipated to be completed by March 22, 2024.
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Affiliation(s)
- Mahdi Vajdi
- Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fariborz Khorvash
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hossein Rouhani
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abed Ghavami
- Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Cain C T Clark
- Institute for Health and Wellbeing, Coventry University, Coventry, CV1 5FB, UK
| | - Gholamreza Askari
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Piccininni M, Brinks R, Rohmann JL, Kurth T. Estimation of migraine prevalence considering active and inactive states across different age groups. J Headache Pain 2023; 24:83. [PMID: 37430201 DOI: 10.1186/s10194-023-01624-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Migraine is a very common headache disorder on the population level, characterized by symptomatic attacks (activity). For many people with migraine, the migraine symptoms intermittently or permanently cease during their lifetime (inactive migraine). The current diagnostic classification of migraine considers two states: active migraine (having migraine symptoms within the last year) and not having active migraine (including both individuals with inactive migraine and those who never had migraine). Defining a state of inactive migraine that has gone into remission may better capture the trajectories of migraine across the lifespan and contribute to a better understanding of its biological processes. We aimed to quantify the prevalence of never, active, and inactive migraine separately, using modern prevalence and incidence estimation methodology to better describe the complexity of migraine trajectories at the population level. METHODS Using a multistate modeling approach, data from the Global Burden of Disease (GBD) study, and results from a population-based study, we estimated the transition rates by which individuals moved between migraine disease states and estimated prevalences of never, active and inactive migraine. We used data from the GBD project and a hypothetical cohort of 100,000 people with a starting age of 30 and 30 years of follow-up, both in Germany and globally, stratified by sex. RESULTS In Germany, the estimated rate of transition from active to inactive migraine (remission rate) increased after the age of 22.5 in women and 27.5 in men. The pattern for men in Germany was similar to the one observed on the global level. The prevalence of inactive migraine among women reaches 25.7% in Germany and 16.5% globally at age 60. For men, the inactive migraine prevalence estimates at the same age were 10.4% in Germany and 7.1% globally. CONCLUSIONS Considering an inactive migraine state explicitly reflects a different epidemiological picture of migraine across the lifecourse. We have demonstrated that many women of older ages may be in an inactive migraine state. Many pressing research questions can only be answered if population-based cohort studies collect information not only on active migraine but also on inactive migraine states.
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Affiliation(s)
- Marco Piccininni
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ralph Brinks
- Chair for Medical Biometry and Epidemiology, Faculty of Health/School of Medicine, Witten/Herdecke University, Alfred-Herrhausen-Straße 45, 58455, Witten, Germany
| | - Jessica L Rohmann
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Robert-Rössle-Straße 10, 13125, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Park SY, Kim J. Characteristics of patients who visited emergency departments for headache in South Korea: A descriptive cross-sectional study. Headache 2023; 63:795-804. [PMID: 37140127 DOI: 10.1111/head.14511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE This study aimed to describe the characteristics of adult patients who visit emergency departments (EDs) for non-traumatic headache in South Korea. BACKGROUND Little is known about East Asian patients who visit EDs for headache. METHODS This observational, descriptive, cross-sectional study retrospectively analyzed 2019 National Emergency Department Information System data, including age, sex, co-occurring fever, symptom duration, insurance type, transportation mode, ED level, triage level, ED visit time, specialist consultations at the ED, disposition from the ED, and outcomes. The proportion of patients with a life-threatening secondary headache and the diagnostic codes were investigated. RESULTS A total of 227,288 patients were observed in this study, accounting for 2.2% (227,288/10,238,360) of all ED visits. Females (63.1%; 143,493/227,288) visited EDs more than males, and patients aged 50-60 years (21.0%; 47,637/227,288) visited most frequently. A total of 61.5% (93,789/151,494) of ED visits were within 24 h after headache onset, and 57.6% (131,056/227,288) of visits were assigned to non-urgent triage levels. The most frequent discharge codes were "R51: Headache (not better specified)" from the ED and ward, and "I60: Subarachnoid hemorrhage" from the intensive care unit. The rate of migraine diagnosis was 7.2% (16,471/227,288). A total of 3.1% (7153/227,288) of patients were diagnosed with life-threatening secondary headaches, most commonly subarachnoid hemorrhage (1.2%; 2744/227,288) and cerebral infarction (0.6%; 1341/227,288). CONCLUSIONS In South Korea, the characteristics of patients who visited the ED for non-traumatic headache were not very different from those in existing studies; however, patients tended to visit EDs early and be classified as non-urgent, and emergency physicians tended to enter the diagnosis code "R51: Headache (not better specified)", resulting in a much lower rate of migraine diagnoses. Non-urgent early visitors coded with "R51" may include those who have not yet been diagnosed with primary headache and have not been treated, but who need further research. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, College of Medicine, Dong-A University Hospital, Dong-A University, Busan, South Korea
| | - Jiyoung Kim
- Department of Neurology and Sleep Disorder Center, Bio Medical Research Institute, College of Medicine, Pusan National University School of Medicine, Pusan National University Hospital, Busan, South Korea
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García-Azorín D, Abelaira-Freire J, Rodriguez-Adrada E, González-García N, Guerrero ÁL, Porta-Etessam J, Martín-Sánchez FJ. Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache. NEUROLOGÍA (ENGLISH EDITION) 2023; 38:270-277. [PMID: 37030513 DOI: 10.1016/j.nrleng.2020.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/14/2020] [Indexed: 04/08/2023] Open
Abstract
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 1120 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, 2 patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and 5 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.
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Affiliation(s)
- D García-Azorín
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - J Abelaira-Freire
- Servicio de Emergencias, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - N González-García
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Á L Guerrero
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Valladolid, Valladolid, Spain
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain.
| | - F J Martín-Sánchez
- Servicio de Emergencias, Hospital Clínico Universitario San Carlos, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
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Almuqbil M, Alsayed SA, Almutairi AM, Aladhadh KM, Alghannami AO, Almutairi M. Diagnostic Yield of Neuroimaging for Headache in a Pediatric Emergency Department: A Single Tertiary Centre Experience. Healthcare (Basel) 2023; 11:healthcare11060913. [PMID: 36981570 PMCID: PMC10048237 DOI: 10.3390/healthcare11060913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
OBJECTIVES This study aimed to examine headache neuroimaging findings among the pediatric population visiting the emergency department in Saudi Arabia. METHODS This was a cross-sectional retrospective study of pediatric patients who presented to the emergency department with a headache as their primary complaint. Data were extracted from the electronic medical files of the patients at King Abdullah Specialized Children Hospital (KASCH) between 2015 and 2020. The diagnosis of headache was confirmed using a computerized tomography (CT) scan or magnetic resonance imaging (MRI) upon the patients' presentation. RESULTS A total of 263 patients met the inclusion criteria, and their data were extracted. The CT scans were abnormal in 50% of the patients. The MRI showed abnormal findings for 26% of the patients. CT scans and MRI identified that abnormalities were predominantly among patients with the secondary type of headache. The most common abnormal findings on CT were sinusitis (16%), masses (7%), and hydrocephalus (7%). The most common abnormal findings on MRI were masses (8%), cysts (5%), and hydrocephalus (3%). Of all patients with headaches, 10% had a prior diagnosis of headache, and 12% had a family history of headache. A significantly higher percentage of patients with secondary headache were prescribed NSAID and required admission compared to patients with primary headache (p ≤ 0.05). There was no statistically significant differences in the proportion of patients diagnosed with primary and secondary headache in terms of their neurological examination and headache types (p = 0.43). CONCLUSIONS Neuroimaging is essential for diagnosing headaches in children. Headaches were associated with sinusitis in children. The secondary type was more likely to have abnormal CT and MRI results. Primary type headaches were more common in those with a family history. CT scans and MRIs are needed when a headache is accompanied by an abnormal clinical evaluation. Neuroimaging and mild CT usage may be explored if there are clinical abnormalities or family history.
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Affiliation(s)
- Mohammed Almuqbil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
- Pediatric Emergency Department, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh 52569, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh 11481, Saudi Arabia
| | - Saud Abdulaziz Alsayed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Amer Mohammed Almutairi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Khalid Mohammed Aladhadh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Abdullah Omar Alghannami
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh 11481, Saudi Arabia
| | - Mohammed Almutairi
- Pediatric Emergency Department, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh 52569, Saudi Arabia
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Ardila CM, Gonzalez-Arroyave D, Angel S, Zuluaga-Gomez M. Primary Headache Approach in the Emergency Departments: A Systematic Scoping Review of Prospective Studies. Cureus 2023; 15:e36131. [PMID: 37065368 PMCID: PMC10100244 DOI: 10.7759/cureus.36131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/16/2023] Open
Abstract
This systematic scoping review aims to answer questions related to the main characteristics of primary headache, the need for neuroimaging, and the presence of red flags in these patients. A review of prospective studies including the MEDLINE/PubMed, Scopus, LILACS, and SCIELO databases, as well as the grey literature, was conducted. The methodological quality of the selected investigations was also assessed. Six investigations met the selection criteria. The mean age of people with primary headache was less than 43 years, with ages ranging from 39 to 46 years. Most of the studies reported the presence of nausea/vomiting, between 12% and 60% of the patients studied. To a lesser extent, there was also the presence of intense and moderate pain, loss of consciousness, stiff neck, presence of aura, and photophobia. The most frequent diagnoses were unspecified headache, migraine, and tension headache. The studies did not recommend neuroimaging and no red flags were reported. Primary headache occurred more frequently in women, in those under 46 years of age with a history of migraine and similar episodes. Moreover, the presence of red flags and the need for neuroimaging in patients with primary headaches were not evidenced.
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Diagnostic yield of emergency MRI in non-traumatic headache. Neuroradiology 2023; 65:89-96. [PMID: 36029327 PMCID: PMC9816281 DOI: 10.1007/s00234-022-03044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/16/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Non-traumatic headache is one of the most common neurological complaints in emergency departments. A relatively low diagnostic yield of magnetic resonance imaging (MRI) among outpatients has been previously reported, but studies of emergency patients are lacking. We sought to determine the diagnostic yield of emergency MRI among outpatients presenting to the emergency department with non-traumatic headache. METHODS In this retrospective cohort study, we analyzed emergency MRI referrals in a tertiary hospital for non-traumatic headache over a five-year period. We recorded patient characteristics, relevant clinical information from the referrals, and imaging outcomes. RESULTS In total, 696 emergency patients with non-traumatic headache underwent MRI, most within 24 h of presentation. Significant findings related to headache were found in 136 (20%) patients, and incidental findings in 22% of patients. In a multivariate model, the predisposing factors of the significant findings were age, smoking, nausea, and signs/symptoms of infection. The protective factors were numbness and history of migraine. A predictive clinical score reached only moderate performance. CONCLUSION Although emergency MRI shows headache-related findings in one in five patients, accurate prediction modeling remains a challenge, even with statistically significant predictors and a large sample size.
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Shojaei M, Sahebkar A, Khorvash F, Fallahpour S, Askari G, Bagherniya M. The effects of phytosomal curcumin supplementation on clinical symptoms, and inflammatory and oxidative stress biomarkers in patients with migraine: A protocol for a randomized double-blind placebo-controlled trial. AVICENNA JOURNAL OF PHYTOMEDICINE 2023; 13:45-57. [PMID: 36698737 PMCID: PMC9840775 DOI: 10.22038/ajp.2022.21242] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 01/27/2023]
Abstract
Objective Migraine is one of the most common diseases. Curcumin with anti-oxidative and anti-neuroinflammatory properties might have beneficial effects in migraine patients. This study will be conducted to evaluate the effects of a phytosomal preparation of curcumin on clinical signs, oxidative stress, and inflammatory parameters in patients with migraine. Materials and Methods This is a randomized, double-blind, placebo-controlled, clinical trial in which, 60 patients with migraine will be assigned to receive a daily dose of 250 mg of phytosomal curcumin for 8 weeks (intervention group) or 250 mg maltodextrin as a placebo for the same duration (control group). Before and after the study, frequency, duration, and severity of the attacks, quality of life and sleep, mood status, high-sensitivity C-reactive protein (hs-CRP), Nitric Oxide (NO), and oxidative stress factors will be measured. Conclusion It seems that phytosomal formulation of curcumin (a solid dispersion preparation of curcumin with phosphatidylserine) with high bioavailability, can cross the blood-brain barrier (BBB) and result in decreased neuroinflammation, oxidative stress, and neurotoxicity. This way, phytosomal curcumin might lead to reduction of headaches and other complications of migraine and increase the quality of life of patients with migraine.
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Affiliation(s)
- Mehrnaz Shojaei
- Student Research Committee, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhossein Sahebkar
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fariborz Khorvash
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Soheil Fallahpour
- Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamreza Askari
- Nutrition and Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
- Anesthesia and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Bagherniya
- Nutrition and Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
- Anesthesia and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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12
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A machine learning approach to support triaging of primary versus secondary headache patients using complete blood count. PLoS One 2023; 18:e0282237. [PMID: 36877693 PMCID: PMC9987784 DOI: 10.1371/journal.pone.0282237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/09/2023] [Indexed: 03/07/2023] Open
Abstract
Headaches account for up to 4.5% of emergency department visits, where they present a significant diagnostic challenge. While primary headaches are benign, secondary headaches can be life-threatening. It is essential to rapidly differentiate between primary and secondary headaches as the latter require immediate diagnostic work-up. Current assessment relies on subjective measures; time constraints can result in overuse of diagnostic neuroimaging, prolonging diagnosis, and adding to economic burden. There is therefore an unmet need for a time- and cost-efficient, quantitative triaging tool to guide further diagnostic testing. Routine blood tests may provide important diagnostic and prognostic biomarkers indicating underlying headache causes. In this retrospective study (approved by the UK Medicines and Healthcare products Regulatory Agency Independent Scientific Advisory Committee for Clinical Practice Research Datalink (CPRD) research [20_000173]), UK CPRD real-world data from patients (n = 121,241) presenting with headache from 1993-2021 were used to generate a predictive model based on a machine learning (ML) approach for primary versus secondary headaches. A ML-based predictive model was constructed using two different methods (logistic regression and random forest) and the following predictors were evaluated: ten standard measurements of complete blood count (CBC) test, 19 ratios of the ten CBC test parameters, and patient demographic and clinical characteristics. The model's predictive performance was assessed using a set of cross-validated model performance metrics. The final predictive model showed modest predictive accuracy using the random forest method (balanced accuracy: 0.7405). The sensitivity, specificity, false negative rate (incorrect prediction of secondary headache as primary headache), and false positive rate (incorrect prediction of primary headache as secondary headache) were 58%, 90%, 10%, and 42%, respectively. The ML-based prediction model developed could provide a useful time- and cost-effective quantitative clinical tool to facilitate the triaging of patients presenting to the clinic with headache.
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Comparative Effects of Mulligan's Mobilization, Spinal Manipulation, and Conventional Massage Therapy in Cervicogenic Headache-A Prospective, Randomized, Controlled Trial. Healthcare (Basel) 2022; 11:healthcare11010107. [PMID: 36611567 PMCID: PMC9819355 DOI: 10.3390/healthcare11010107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Background: There is ample evidence supporting the use of manual therapy techniques for the treatment of cervicogenic headache (CGH). Objective: The objective of this study was to find and compare the effects of different manual therapy approaches to cervicogenic headache. Methods: A randomized, controlled study was conducted on 84 CGH participants at the university hospital. The participants were divided into a Mulligan mobilization therapy group (MMT; n = 28), a spinal manipulation therapy group (SMT; n = 28), and a control group (Control; n = 28); they received the respective treatments for four weeks. The primary outcome (CGH frequency) and secondary outcomes (CGH pain intensity, CGH disability, neck pain frequency, pain intensity, pain threshold, flexion rotation (right and left), neck disability index, and quality of life scores) were measured at baseline, after 4 weeks, after 8 weeks, and at a 6-month follow-up. The one-way ANOVA test and repeated measures analysis of variance (rANOVA) test were performed to find the difference between the inter- and intra-treatment group effects. Results: Four weeks following training, the MMT group showed a statistically significant difference in the primary (CGH frequency) and secondary (CGH pain intensity, CGH disability, neck pain frequency, neck pain intensity, flexion rotation test, neck disability index, and quality of life) scores than those of the SMT and control groups (p < 0.001). The same difference was seen in the above variables at 8 weeks and at the 6-month follow-up. At the same time, the neck pain threshold level did not show any difference at the 4-week and the 8-week follow-up (p ≥ 0.05) but showed statistical difference at the 6-month follow-up. Conclusion: The study concluded that Mulligan’s mobilization therapy provided better outcomes in cervicogenic headache than those of spinal manipulation therapy and conventional massage therapy.
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García-Azorín D, Abelaira-Freire J, González-García N, Rodriguez-Adrada E, Schytz HW, Barloese M, Guerrero ÁL, Porta-Etessam J, Martín-Sánchez FJ. Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection. Cephalalgia 2022; 42:1521-1531. [PMID: 36003002 DOI: 10.1177/03331024221120249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the diagnostic accuracy of the SNNOOP10 list in the detection of high-risk headaches. METHODS Patients that visited the Hospital Clínico San Carlos (Madrid) emergency department due to headache that were allocated to a Manchester Triage System level between critical and urgent were prospectively included but retrospectively analysed. A researcher blind to the patients' diagnosis administered a standardised questionnaire and afterwards a neurologist blind to the questionnaire results diagnosed the patient according to the International Classification of Headache Disorders. The primary endpoint was to assess the sensitivity of the SNNOOP10 list in the detection of high-risk headaches. Secondary endpoints included the evaluation of the sensitivity, specificity, positive predictive value, negative predictive value and area under the curve of each SNNOOP10 item. RESULTS Between April 2015 and October 2021, 100 patients were included. Patients were 44 years old (inter-quartile range: 33.6-64.7) and 57% were female. We identified 37 different diagnoses. Final diagnosis was a primary headache in 33%, secondary headache in 65% and cranial neuralgia in 2%. There were 46 patients that were considered as having high-risk headache. Patients from the primary headache group were younger and more frequently female. Sensitivity of SNNOOP10 list was 100% (95% confidence interval: 90.2%-100%). The items with higher sensitivity were neurologic deficit or disfunction (75.5%), pattern change or recent onset of the headache (64.4%), onset after 50 years (64.4%). The most specific items were posttraumatic onset of headache (94.5%), neoplasm in history (89.1%) and systemic symptoms (89%). The area under the curve of the SNNOOP10 list was 0.66 (95% CI: 0.55-0.76). CONCLUSION The red flags from the SNNOOP10 list showed a 100% sensitivity in the detection of high-risk headache disorders.
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Affiliation(s)
- David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Nuria González-García
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Henrik Winther Schytz
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mads Barloese
- Center for Functional and Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Ángel Luis Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain.,Institute of Biomedical Research of Salamanca (Ibsal), Salamanca, Spain
| | - Jesús Porta-Etessam
- Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain.,Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Francisco Javier Martín-Sánchez
- Emergency Department, Hospital Clínico Universitario San Carlos, Madrid, Spain.,Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
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15
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Iskorur C, Korkut M, Soyuncu S. The relationship between abnormal intracranial findings in brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache: a prospective cohort study. Clin Exp Emerg Med 2022; 9:134-139. [PMID: 35843614 PMCID: PMC9288873 DOI: 10.15441/ceem.21.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to investigate the relationship between abnormal intracranial findings on brain computed tomography and antiplatelet or anticoagulant use in patients with nontraumatic headache in the emergency department (ED).Methods This was a single-center prospective observational study of patients admitted to the tertiary ED with complaints of nontraumatic headache between May 1, 2016 and September 1, 2016. Anticoagulant or antiplatelet drug use by the patient was recorded. Brain computed tomography (CT) results were categorized into two groups, abnormal results (CT positive) and no pathologic results (CT negative), and compared. The CT positive group included any pathological signs in the brain and the negative group was considered a normal read. A logistic regression analysis was used for evaluating the association of antiplatelets and anticoagulants with abnormal CT findings.Results Of the 837 patients with nontraumatic headaches, 157 (18.8%) patients who underwent brain CT scanning were included. The mean age of the patients was 44.4±16.7 years. Eighty-eight (56.1%) of the patients were women. Of the 29 (18.4%) patients using antiplatelets or anticoagulants, 16 (55.2%) were in the CT positive group. There was a statistically significant difference between both groups in terms of drug use compared to the CT negative group (P<0.001). Factors affecting CT results were examined in logistic regression analysis and a statistically significant difference was found in the detection of positive results in antiplatelet or anticoagulant drug users (adjusted odds ratio, 2.478; 95% confidence interval, 1.006–6.102; P=0.048).Conclusion The use of antiplatelets or anticoagulants in patients admitted to the ED with nontraumatic headache is associated with an increased risk of abnormal intracranial results in brain CT.
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16
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Zabek MM, Turek G. Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension. Surg Neurol Int 2022; 13:215. [PMID: 35673655 PMCID: PMC9168387 DOI: 10.25259/sni_360_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Spontaneous intracranial hypotension (SIH) is a rare disease characterized by a decrease in the volume and pressure of cerebrospinal fluid (CSF) resulting from its leakage through the dura mater. SIH is curable, but it can lead to serious clinical sequelae or even death if not treated properly. Case Description: A 37-year-old female with headaches occurring in standing position and increasing especially during verticalization. Magnetic resonance imaging showed an image characteristic of SIH. Conservative treatment was applied in the form of bed rest. CT myelography scan located the site of CSF leakage. As the conservative treatment proved inefficient, it was decided to perform an epidural fistula sealing using the patient’s venous blood, administered under computed tomography guidance. The performed procedure completely resolved the patient’s complaints, allowing her to be discharged home. Conclusion: Patients with suspected SIH should remain in the supine position until a definitive diagnosis is made. Sealing the meningeal fistula with venous blood under computed tomography guidance should be considered in case of conservative treatment failure.
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Affiliation(s)
| | - Grzegorz Turek
- Department of Neurosurgery, Brodno Masovian Hospital, Warsaw, Poland
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17
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Rimmele F, Janke J, Kropp P, Kasch R, Walter U, Jürgens TP. Headache in the Neurological Emergency Department—High Degree of Inadequate Documentation Calls for Structured Assessments. Front Neurol 2022; 13:847484. [PMID: 35401419 PMCID: PMC8987986 DOI: 10.3389/fneur.2022.847484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
Headaches are a frequent reason for presentation to the emergency department (ED) and can pose a great challenge for the attending physicians. First and foremost, the distinction between a primary and secondary headache with potentially life-threatening implications can be difficult. Moreover, it often occurs that no specific headache diagnosis is made at discharge from the ED. Therefore, in this present retrospective cross-sectional study, all patients who presented to the emergency department of the Department of Neurology at Rostock University Medical Centre with the main symptom of headache between November 2013 and November 2016 underwent a neurological examination and the extent to which warning symptoms (“red flags”) for a secondary headache as well as symptoms necessary for a correct headache diagnosis according to the ICHD-3 classification were recorded and documented. We could show that documentation of red flags and clinical characteristics is inadequate and does not allow proper diagnostic categorization. To facilitate concise documentation and rapid decision making we suggest a structured and standardized form for documenting the headache history and red flags in the ED.
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Affiliation(s)
- Florian Rimmele
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
- *Correspondence: Florian Rimmele
| | - Josephine Janke
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University Medical Center Rostock, Rostock, Germany
| | - Ramon Kasch
- Department of Neurology, KMG Klinikum Güstrow, Güstrow, Germany
| | - Uwe Walter
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Tim P. Jürgens
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
- Department of Neurology, KMG Klinikum Güstrow, Güstrow, Germany
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18
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Yang S, Orlova Y, Lipe A, Boren M, Hincapie-Castillo JM, Park H, Chang CY, Wilson DL, Adkins L, Lo-Ciganic WH. Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007-2018 National Hospital Ambulatory Medical Care Survey Data. J Clin Med 2022; 11:jcm11051401. [PMID: 35268492 PMCID: PMC8910868 DOI: 10.3390/jcm11051401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 12/10/2022] Open
Abstract
We examined trends in management of headache disorders in United States (US) emergency department (ED) visits. We conducted a cross-sectional study using 2007−2018 National Hospital Ambulatory Medical Care Survey data. We included adult patient visits (≥18 years) with a primary ED discharge diagnosis of headache. We classified headache medications by pharmacological group: opioids, butalbital, ergot alkaloids/triptans, acetaminophen/nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, diphenhydramine, corticosteroids, and intravenous fluids. To obtain reliable estimates, we aggregated data into three time periods: 2007−2010, 2011−2014, and 2015−2018. Using multivariable logistic regression, we examined medication, neuroimaging, and outpatient referral trends, separately. Among headache-related ED visits, opioid use decreased from 54.1% in 2007−2010 to 28.3% in 2015−2018 (Ptrend < 0.001). There were statistically significant increasing trends in acetaminophen/NSAIDs, diphenhydramine, and corticosteroids use (all Ptrend < 0.001). Changes in butalbital (6.4%), ergot alkaloid/triptan (4.7%), antiemetic (59.2% in 2015−2018), and neuroimaging (37.3%) use over time were insignificant. Headache-related ED visits with outpatient referral for follow-up increased slightly from 73.3% in 2007−2010 to 79.7% in 2015−2018 (Ptrend = 0.02). Reflecting evidence-based guideline recommendations for headache management, opioid use substantially decreased from 2007 to 2018 among US headache-related ED visits. Future studies are warranted to identify strategies to promote evidence-based treatment for headaches (e.g., sumatriptan, dexamethasone) and appropriate outpatient referral and reduce unnecessary neuroimaging orders in EDs.
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Affiliation(s)
- Seonkyeong Yang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Yulia Orlova
- Neurology Department, College of Medicine, University of Florida, Gainesville, FL 32611, USA;
| | - Abigale Lipe
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Macy Boren
- College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (A.L.); (M.B.)
| | - Juan M. Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Haesuk Park
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
| | - Ching-Yuan Chang
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
| | - Lauren Adkins
- Health Science Center Libraries, University of Florida, Gainesville, FL 32611, USA;
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA; (S.Y.); (H.P.); (C.-Y.C.); (D.L.W.)
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, FL 32611, USA
- Correspondence: ; Tel.: +1-352-273-6255
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Rankin S, McGuire J, Chekroud M, Alakandy L, Mukhopadhyay B. Evaluating xanthochromia in the diagnosis of subarachnoid haemorrhage in Scotland in the Era of modern computed tomography. Scott Med J 2022; 67:71-77. [PMID: 35105220 DOI: 10.1177/00369330211072264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Cerebrospinal fluid (CSF) analysis for xanthochromia is routinely used to exclude subarachnoid haemorrhage (SAH). In this study, we evaluated the sensitivity and specificity of xanthochromia (by NEQAS-spectrophotometry) in routine clinical practice in three acute hospitals, in patients with suspected SAH. We explored whether including CSF red cell count (RCC) with xanthochromia improved diagnostic accuracy. METHODS In this retrospective analysis, all xanthochromia results were assessed over three consecutive years. Clinical information and Registry data were analysed to find all patients diagnosed with SAH. We correlated xanthochromia data with clinical and radiological findings. RESULTS There were 1761 xanthochromia performed. Of these, 26 (1.5%) were positive, 1624 (92%) negative and 72 (4.1%) were inconclusive. Of the 26 tests that were positive, 9 (35%) had confirmed SAH, 17 (65%) were falsely positive, with no false negative tests in our series. Xanthochromia identified 6% of all SAH diagnosed in the study. Incorporating RCC <1000 with xanthochromia, reducing false positive tests by 38% and inconclusive test by 85%. CONCLUSION The positive yield of xanthochromia is low but identified 6% of SAH. NEQAS-spectrophotometry is an excellent diagnostic method with 100% sensitivity, 99% specificity. Incorporating RCC markedly reduces false positive and inconclusive tests reducing need for further imaging.
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Affiliation(s)
- Stephen Rankin
- Internal Medicine, 3529NHS Greater Glasgow & Clyde, UK.,College of Medical, Veterinary and Life Sciences affiliated to the School of Medicine, 3526University of Glasgow, Glasgow, UK
| | - Jacqueline McGuire
- Clinical Biochemistry, 59739University Hospital Hairmyres, East Kilbride, South Lanarkshire, UK
| | - Mohamed Chekroud
- Emergency Medicine, 59739University Hospital Hairmyres, East Kilbride, South Lanarkshire, UK
| | - Likhith Alakandy
- Neurosurgery, 195153Institute of Neurological Sciences, Glasgow, UK
| | - Babu Mukhopadhyay
- College of Medical, Veterinary and Life Sciences affiliated to the School of Medicine, 3526University of Glasgow, Glasgow, UK.,Internal Medicine, 59739University Hospital Hairmyres, East Kilbride, South Lanarkshire, UK
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20
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Granato A, D'Acunto L, Morelli ME, Bellavita G, Cominotto F, Manganotti P. Lost diagnoses in not otherwise specified headache in Emergency Department. Acta Neurol Belg 2022; 122:129-134. [PMID: 34449048 PMCID: PMC8894300 DOI: 10.1007/s13760-021-01687-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Abstract
The diagnosis of Not Otherwise Specified (NOS) headaches in the Emergency Department (ED) is frequent despite many specialist visits performed. The aim of the study was to examine specialist visits carried out in the patients discharged from ED with diagnosis of NOS headache to evaluate discrepancies between specialist and ED diagnosis at discharge. We retrospectively (1.6.2018–31.12.2018) analyzed all the patients admitted with non-traumatic headache to the ED of the tertiary-care University Hospital of Trieste. We evaluated the patients discharged from ED with a final diagnosis of NOS headache and who underwent at least one specialist examination. Demographic data, specialist and ED diagnosis were analyzed. One hundred twenty-four patients (93 F, 31 M, mean age 44 ± 15 years) were included. 71.8% of patients were examined only by a neurologist, 12.9% by non-neurologists, 15.3% by both neurologist and non-neurologist. Only 37% of the patients received a precise diagnosis. Neurologist made a diagnosis slightly more frequently than the other consultants (40.5% vs 37.5%). Neurologists diagnosed primary headaches, headaches secondary to neurological diseases, and facial neuralgia, instead non-neurologists diagnosed only headaches secondary to non-neurological diseases. Primary headaches were diagnosed in 25.7% of cases, migraine being the most frequent. Physicians did not report any specialist diagnoses in the ED discharge sheet. Specialist consultants made specific diagnoses in about one-third of patients that were not reported as final in the discharge records by the ED physician. This leads to a loss of diagnoses and to an overestimation of NOS headache.
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Affiliation(s)
- Antonio Granato
- Clinical Unit of Neurology, Headache Centre, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste-ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Laura D'Acunto
- Clinical Unit of Neurology, Headache Centre, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste-ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Maria Elisa Morelli
- Clinical Unit of Neurology, Headache Centre, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste-ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Giulia Bellavita
- Clinical Unit of Neurology, Headache Centre, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste-ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Franco Cominotto
- Emergency Department, University Hospital and Health Services of Trieste, Strada di Fiume 447, 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Headache Centre, Department of Medicine, Surgery and Health Sciences, University Hospital and Health Services of Trieste-ASUGI, University of Trieste, Strada di Fiume 447, 34149, Trieste, Italy.
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21
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Neumeier MS, Stattmann M, Wegener S, Gantenbein AR, Pohl H. Interrater agreement in headache diagnoses. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221115391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Diagnosing headache disorders comprises the collection and interpretation of information. This study estimates agreement and bias in the latter. Methods: Physicians and medical students diagnosed eight patients’ headaches using the International Classification of Headache Disorders. We calculated Cohen’s Kappa for all participants and subgroups (board-certified neurologists, physicians working in a neurology department). Moreover, we asked how sure they felt about their diagnoses. Finally, participants estimated the number of different headache diagnoses a patient receives when consulting many physicians for the same headache and indicated the highest acceptable number. Results: The data of 63 participants entered the analysis, of whom 18 were neurologists (18/63, 28.6%), and 41 were currently working at a neurology clinic (41/63, 66.7%). Cohen’s Kappa decreased (0.706, 0.566, and 0.408) with increasing levels of the classification hierarchy. Interrater agreement was highest among neurologists. Physicians not working in a neurology clinic tended to diagnose secondary headaches more often were less confident about their diagnoses. Conclusions: Physicians with less experience in headache disorders struggle more to diagnose headaches than neurologists do; they suspect secondary headaches, disagree, and feel insecure more often. Thus, interpreting a headache history is prone to error and bias.
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Affiliation(s)
| | - Miranda Stattmann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Andreas R Gantenbein
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, Zurzach Care, Bad Zurzach, Switzerland
| | - Heiko Pohl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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Do TP, la Cour Karottki NF, Ashina M. Updates in the Diagnostic Approach of Headache. Curr Pain Headache Rep 2021; 25:80. [PMID: 34894320 DOI: 10.1007/s11916-021-00995-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW In this review, we summarize updates in the diagnostic approach of headaches with the aim of facilitating the distinction between primary and secondary etiology in headaches. RECENT FINDINGS In the USA, headache is the fifth most common complaint in the emergency department, but only a minority will have a secondary etiology. Initial suspicion and diagnostic workup of secondary headache relies on a patient's medical history due to a scarcity of validated biomarkers. A special interest group under the International Headache Society recently synthesized information on red flags (information that indicates a secondary etiology) and green flags (information that indicates a primary etiology). A systematic diagnostic approach using red flags and green flags can help reduce unnecessary testing and shift attention to patient care. Going forward, further validation of these concepts is needed to properly introduce them for clinical use.
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Affiliation(s)
- Thien Phu Do
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Folke la Cour Karottki
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,Danish Knowledge Center On Headache Disorders, Glostrup, Denmark. .,Department of Nervous Diseases of the Institute of Professional Education, IM Sechenov First Moscow State Medical University, Moscow, Russia. .,Department of Neurology, Azerbaijan Medical University, Baku, Azerbaijan.
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23
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Yuan H, Curran JG, Keith SW, Hopkins MM, Silberstein SD. Intravenous ibuprofen for acute treatment of migraine: A double-blind, randomized, placebo-controlled pilot study. Headache 2021; 61:1432-1440. [PMID: 34601736 DOI: 10.1111/head.14214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/22/2021] [Accepted: 08/18/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous (IV) Ibuprofen for acute treatment of migraine. BACKGROUND IV nonsteroidal anti-inflammatory drugs (NSAIDs) are an alternative to oral NSAIDs, especially in patients with severe migraine who have emesis or gastroparesis. To date, only three IV NSAIDs (ketorolac, ibuprofen, and meloxicam) are available in the United States for use in moderate and severe pain, but no placebo-controlled trial is available for migraine. We performed a single-center, double-blind, randomized, placebo-controlled pilot study to evaluate the efficacy and safety of IV ibuprofen as an acute treatment of migraine (NCT01230411). METHODS Individuals with episodic migraine were screened at the Jefferson Headache Center. Qualified subjects were treated for migraine attacks within 2-72 h following the headache onset with either 800 mg of IV ibuprofen or placebo in 250 ml saline bolus. Migraine pain intensity (4-point Likert scale) and associated symptoms were assessed at predetermined time points (0.25, 0.5, 1, 1.5, 2, 4, 8, 24 h). The primary endpoint was pain relief at 2 h after infusion. Important secondary endpoints included pain freedom at 2 h, sustained relief over 24 h, use of rescue therapy, and absence of associated symptoms. Adverse events (AEs) were also collected. RESULTS Seventy-four participants were enrolled between 2011 and 2017. Forty-four subjects (female 33/44; 75.0%) with mean (SD) age 41.0 (11.2) 11.2 years came for the treatment. All treated subjects (n = 44) were included in the analysis. Among them, 23 were randomized to receive IV ibuprofen. Both groups were demographically similar except for longer migraine duration (i.e., years lived with disease) in the active treatment than in the placebo group. At 2 h posttreatment, pain relief was found in 74% (17/23) and 48% (10/21) after IV ibuprofen and placebo, respectively (odds ratio [OR] 3.12, 95% CI: 0.88-11.0; p = 0.078). Other secondary endpoints at 2 and 24 h were not significant. The longitudinal repeated-measures analysis within 2 h on ibuprofen treatment showed significant pain relief (OR 2.47, 95% CI 1.08-5.7; p = 0.033) and absence of associated symptoms: photophobia (OR 4.0, 95% CI 1.57-10.3; p = 0.004), phonophobia (OR 3.12, 95% CI 1.16-8.4; p = 0.025), and osmophobia (OR 3.45, 95% CI 1.01-11.8; p = 0.048). AEs were observed in seven subjects in both groups, with arm pain being the most common. No serious AE was reported. CONCLUSION This study did not meet the primary endpoint but showed pain relief and elimination of several associated symptoms within 2 h on repeated-measures analysis. Although limited by small sample size and high placebo response, our results indicate that IV ibuprofen may be a safe and effective option for acute treatment of migraine, but more extensive studies are necessary.
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Affiliation(s)
- Hsiangkuo Yuan
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John G Curran
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Scott W Keith
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mary M Hopkins
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen D Silberstein
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Beck S, Kinnear FB, Maree Kelly A, Chu KH, Sen Kuan W, Keijzers G, Body R, Karamercan MA, Klim S, Wijeratne T, Kamona S, Graham CA, Roberts T, Horner D, Laribi S. Clinical presentation and assessment of older patients presenting with headache to emergency departments: A multicentre observational study. Australas J Ageing 2021; 41:126-137. [PMID: 34570422 DOI: 10.1111/ajag.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To describe the characteristics, assessment and management of older emergency department (ED) patients with non-traumatic headache. METHODS Planned sub-study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non-traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. RESULTS A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). CONCLUSION Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non-traumatic headache.
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Affiliation(s)
- Sierra Beck
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Emergency Department, Dunedin Hospital, Dunedin, New Zealand
| | - Frances B Kinnear
- Emergency & Children's Services, The Prince Charles Hospital, Chermside, Qld, Australia.,Department of Medicine, University of Queensland, St Lucia, Qld, Australia
| | - Anne Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Melbourne, Vic., Australia.,Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, Parkville, Vic., Australia
| | - Kevin H Chu
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Qld, Australia.,Faculty of Medicine, University of Queensland, St Lucia, Qld, Australia
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Qld, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia.,School of Medicine, Griffith University, Gold Coast, Qld, Australia
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,Emergency Department, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mehmet A Karamercan
- Faculty of Medicine Department of Emergency Medicine, Gazi University, Ankara, Turkey
| | - Sharon Klim
- Joseph Epstein Centre for Emergency Medicine Research @ Western Health, Sunshine, Melbourne, Vic., Australia
| | - Tissa Wijeratne
- The University of Melbourne, Parkville, Australia.,Department of Neurology, Western Health, St Albans, Vic., Australia.,Public Health School, La Trobe University, Bundoora, Vic., Australia
| | - Sinan Kamona
- School of Medicine, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Colin A Graham
- Emergency Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Tom Roberts
- Trainee Emergency Research Network (TERN), North Bristol NHS Trust, Bristol, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford, UK
| | - Said Laribi
- Emergency Medicine Department, Tours University Hospital, Tours, France.,EUSEM Research Network, Aartselaar, Belgium
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25
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Munoz-Cerón J, Díaz-Forero F, Buitrago A, Chinchilla S. Secondary cluster headache and numb chin syndrome as initial manifestation of high-grade B-lymphoma: a case report. J Med Case Rep 2021; 15:468. [PMID: 34517893 PMCID: PMC8439040 DOI: 10.1186/s13256-021-03016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 07/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cluster headache is a primary condition characterized by severe headache accompanied by trigeminal autonomic signs. By definition, it is not attributed to underlying etiologies; however, under certain clinical characteristics, secondary etiologies must be ruled out. CASE PRESENTATION We present the case of a 48-year-old Hispanic man with a history of episodic right orbital pain, lasting 30 minutes, associated with ipsilateral tearing, who prior to the onset of his symptoms reported loss of appetite, weight loss, and paresthesias in the right chin region. After work-up studies, high-grade lymphoma with infiltration to the right submental nerve was diagnosed, in which numb chin syndrome was the initial presentation. Despite initiation of treatment, the patient died 3 weeks after the diagnosis. CONCLUSIONS In the study of cluster headache, underlying etiologies must be considered when there are atypical clinical manifestations. Within these etiologies, metastases to pericranial nerves must be included, which, besides generating localized symptoms, can activate the trigeminal vascular system simulating headaches of primary etiology.
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Affiliation(s)
- Joe Munoz-Cerón
- Departamento de Neurologia, Hospital Univesitario Mayor MEDERI - Universidad del Rosario, Bogotá, Colombia.
- Departamento de Neurologia , Clinica Univesitaria Colombia - Keralty, Bogotá, Colombia.
| | - Felipe Díaz-Forero
- Departamento de Neurologia, Hospital Univesitario Mayor MEDERI - Universidad del Rosario, Bogotá, Colombia
| | - Adriana Buitrago
- Deparatmento de Medicinia Nuclear - Hospital Univesitario Mayor MEDERI, Universidad del Rosario, Bogotá, Colombia
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26
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Rimmele F, Janke J, Kropp P, Grossmann A, Hamann T, Walter U, Jürgens TP. Headache Characteristics in the Neurological Emergency Department: A Retrospective Study. Front Neurol 2021; 12:706074. [PMID: 34489852 PMCID: PMC8416997 DOI: 10.3389/fneur.2021.706074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: The care of patients with headache in the emergency department (ED) represents a diagnostic and clinical challenge. Data on the prevalence and characteristics of headache patients in purely neurological EDs are sparse. The aim of the present study is to examine patient profiles with the cardinal symptom of headache in an academic neurological ED, to analyze correlations between headache characteristics and search for differences compared to the interdisciplinary ED. Methods: This retrospective cross-sectional study assessed all patients who presented to the ED of the Department of Neurology at Rostock University Medical Center between November 2013 and November 2016 with the main symptom of headache. Epidemiological, clinical, diagnostic data as well as key data regarding the care structure were recorded. Correlations between headache characteristics and diagnosis at discharge were analyzed and risk profiles were identified using binary logistic regression analysis. Conclusion: This study comprehensively characterized a large collective of patients with the cardinal symptom of headache presenting to a purely neurology emergency department.
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Affiliation(s)
- Florian Rimmele
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Josephine Janke
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University Medical Center Rostock, Rostock, Germany
| | - Annette Grossmann
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - Till Hamann
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Uwe Walter
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
| | - Tim P Jürgens
- Department of Neurology, Headache Center North-East, University Medical Center Rostock, Rostock, Germany
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27
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Oliveira LB, Guimarães J, Silva DJD, Jurno ME. Headache diagnosis in an urgency and emergency unit: Public Health Relevance and its relationship with cost. HEADACHE MEDICINE 2021. [DOI: 10.48208/headachemed.2021.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BackgroundHeadache is a common symptom that affects a significant portion of the general population. It constitutes a challenge for diagnosis in urgency and emergency care services, due to headache’s clinical variability and diverse possible etiologies, besides the limited time and resources of these facilities. Because of this insufficiency and the potential severity associated with the condition, headaches generate considerable expenditures to health systems, related to both diagnostic discrimination and treatment.ObjectiveEvaluating the diagnostic resources used on headache patients care, as well as its Public Health Relevanceand relation to cost in an Emergency and Urgency Care unit.MethodsCross-section study analyzing 450 medical records of patients with headache complaints in the time frame from January 1, 2019, and December 31, 2019. Patients were categorized according to the type of headache (primary and secondary), specialized evaluation, complementary exams used in the diagnosis, hospital observation time, and the final expenditure in each patient’s care.ResultsThe total estimated expenditures related to headache care equaled US$90,855.60 (average US$201.90 per patient). 38.9% of cases corresponded to primary headaches and 31.1% to secondary headaches. 30% of cases could not be classified. The resources utilized for secondary headaches diagnosis differed significantly from those used in primary headache diagnosis. However, the final expenditures were similar to both groups.ConclusionThe socio-economic impact caused by headaches is unquestionable. It is a highly frequent symptom and both its etiological distinction and adequate treatment require solid evaluation. Due to the resources spent in its evaluation and monitoring, headaches can be considered a public health problem. Therefore, this study suggests that resources should be allocated in the health education and professional training for the proper conduction of these patients, so that they may benefit from an optimized treatment of theircondition without overwhelming the health system.
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Comparison of recommended use of paraclinical investigations by emergency physicians and neurologists for emergency department patients with headaches: a retrospective observational study. Eur J Emerg Med 2021; 28:240-242. [PMID: 33904530 DOI: 10.1097/mej.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Fierro A, Pérez-Rojí G, Blanco A, López P, Andrés M, González-Quintanilla V, Pérez-Pereda S, Fontanillas N, Pascual J. Headache as main reason for consultation to a hospital Emergency Department in Spain: a prospective study. Neurologia 2021; 38:S0213-4853(21)00089-X. [PMID: 34083062 DOI: 10.1016/j.nrl.2021.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Headache is common in the general population and a frequent reason for medical consultation. OBJECTIVES To describe the characteristics of patients attending the Emergency Department (ED) for headache. METHODS A descriptive study with prospective collection of 100 consecutive patients over 15 years old who attended our ED due to headache as the main complaint. RESULTS Headache accounted for 1,4% of ED visits. The most common age range is between 31 and 45 years and the majority of the patients are females (61%). We diagnosed 67 primary and 33 secondary headaches. The most frequent diagnosis was migraine, with 36% of cases. One out of 3 patients had a history of headache and 4 out of 5 consulted by their own decision. Only a small percentage of patients were admitted as inpatients (12%), and 3 out of 5 were referred to Primary Care. Complementary tests were performed on 84% of the patients. One CT scan was performed for every 3 patients. A total of 80% patients was correctly diagnosed by the ED physicians. CONCLUSIONS Headache is a frequent complaint in the ED, where primary headaches are the most common with migraine being the most frequent reason for consultation. In our setting, there is a good screening and diagnosis of headaches, as well as an adequate use of the available resources in the ED for their diagnosis and management.
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Affiliation(s)
- A Fierro
- Servicio de Neurología, Hospital Universitario Marqués de Valdecilla e IDIVAL y Universidad de Cantabria, Santander, España
| | - G Pérez-Rojí
- Servicio de Urgencias, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - A Blanco
- Servicio de Urgencias, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - P López
- Servicio de Urgencias, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - M Andrés
- Servicio de Urgencias, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - V González-Quintanilla
- Servicio de Neurología, Hospital Universitario Marqués de Valdecilla e IDIVAL y Universidad de Cantabria, Santander, España
| | - S Pérez-Pereda
- Servicio de Neurología, Hospital Universitario Marqués de Valdecilla e IDIVAL y Universidad de Cantabria, Santander, España
| | | | - J Pascual
- Servicio de Neurología, Hospital Universitario Marqués de Valdecilla e IDIVAL y Universidad de Cantabria, Santander, España.
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Effect of synbiotic supplementation on migraine characteristics and inflammatory biomarkers in women with migraine: Results of a randomized controlled trial. Pharmacol Res 2021; 169:105668. [PMID: 33989763 DOI: 10.1016/j.phrs.2021.105668] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/02/2021] [Accepted: 05/06/2021] [Indexed: 12/19/2022]
Abstract
Literature suggests a relationship between gut microbiome and migraine headache pathogenesis. However, the effect of manipulating gut microbiome on migraine remains unclear. This study aimed to investigate the effect of synbiotics on migraine characteristics and inflammatory markers in women with migraines. Sixty-nine participants completed a randomized double-blind controlled trial, receiving synbiotic (109 CFU of 12 types of probiotics + fructooligosaccharides prebiotic) or placebo supplementation, twice per day for 12 weeks. Migraine severity, migraine days per month, frequency and duration of attacks, number of painkillers consumed, gastrointestinal problems, serum High sensitive C-Reactive Protein (Hs-CRP) (a marker of inflammation) and zonulin (a marker of gut permeability) levels were measured at baseline and the end of the intervention. Bivariate comparison and intention-to-treat (ITT) were used for analysis. Synbiotic supplementation compare to the placebo resulted in a significant reduction in the mean frequency of migraine attacks (-1.02 vs -0.30, respectively, P = 0.011), percentage change of the number of painkillers used (-7.5% vs 27.5%, respectively, P = 0.008) and gastrointestinal problems (-35% vs -2.5%, respectively, P = 0.005), zonulin level (-4.12 vs 0.85 ng/ml, respectively, P = 0.034), and Hs-CRP level (-0.43 vs -0.09 mg/l, respectively, P = 0.022). Reduction in the migraine severity and duration did not reach a statistically significant level. Synbiotic supplementation may be considered as a complementary treatment for women with migraines to improve migraine characteristics and markers of inflammation and gut permeability and reduce the burden of disease.
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Lemmens CMC, van der Linden MC, Jellema K. The Value of Cranial CT Imaging in Patients With Headache at the Emergency Department. Front Neurol 2021; 12:663353. [PMID: 34040577 PMCID: PMC8141591 DOI: 10.3389/fneur.2021.663353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/22/2021] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
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Pohl H, Do TP, García-Azorín D, Hansen JM, Kristoffersen ES, Nelson SE, Obermann M, Sandor PS, Schankin CJ, Schytz HW, Sinclair A, Schoonman GG, Gantenbein AR. Green Flags and headache: A concept study using the Delphi method. Headache 2021; 61:300-309. [PMID: 33405273 DOI: 10.1111/head.14054] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/11/2020] [Accepted: 11/30/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Heiko Pohl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Thien Phu Do
- The Danish Headache Center, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Jakob Møller Hansen
- The Danish Headache Center, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Oslo, Norway.,Department of General Practice, University of Oslo, Oslo, Norway
| | - Sarah E Nelson
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Obermann
- Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany.,Department of Neurology, University of Duisburg-Essen, Essen, Germany
| | - Peter S Sandor
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Departement of Neurology and Neurorehabilitation, RehaClinic Group, Bad Zurzach, Switzerland
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Henrik Winther Schytz
- The Danish Headache Center, Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark
| | - Alexandra Sinclair
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Neurology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Guus G Schoonman
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Andreas R Gantenbein
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Departement of Neurology and Neurorehabilitation, RehaClinic Group, Bad Zurzach, Switzerland
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Recte faciendo, neminem timeas: in ruling out the worst cause of non-traumatic headache. Acta Neurol Belg 2020; 120:1475-1476. [PMID: 32306203 DOI: 10.1007/s13760-020-01357-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
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34
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Zhang Y, Zhao X, Wang Y, Dong Z, Yu S. Prevalence and characteristics of cough headache in a Chinese respiratory clinic. Cephalalgia 2020; 41:366-374. [PMID: 33175591 DOI: 10.1177/0333102420970187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND To evaluate the prevalence, predictive factors and clinical characteristics of cough headache in our respiratory clinic and to investigate the coexistence between cough headache, migraine and tension-type headache. METHOD We consecutively investigated patients referred to our respiratory clinic with complaints of cough and selected patients with cough headaches to complete a structured interview and examination. RESULTS Six hundred and seventy-nine patients with cough were studied and 122 patients were diagnosed with cough headache. The prevalence of cough headache was 18.0% in these coughing patients. According to multivariate analysis, being of an age between 31-50 years was a risk factor for cough headache (OR 2.0). Cough headache was associated with cough severity: Compared with the mild group, the moderate group (OR 2.3) and the severe group (OR 3.3) were more vulnerable to cough headache. Headache severity had a positive correlation with cough severity (ρ = 0.301, p = 0.028), age (ρ = 0.199, p = 0.029), and headache duration (ρ = 0.242, p = 0.008). In cough headache patients, 30.3% had tension-type headache and 10.7% had migraine in the preceding year. CONCLUSIONS Cough headache is not rare in respiratory clinics and the characteristics are somewhat different from those in headache clinics. An age of between 31-50 years and cough severity were risk factors for cough headache. Headache severity was related to cough severity, age and headache duration.
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Affiliation(s)
- Yimo Zhang
- International Headache Center, Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Xin Zhao
- International Headache Center, Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Yan Wang
- International Headache Center, Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Zhao Dong
- International Headache Center, Department of Neurology, Chinese PLA General Hospital, Beijing, China
| | - Shengyuan Yu
- International Headache Center, Department of Neurology, Chinese PLA General Hospital, Beijing, China
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Pérez‐Pereda S, González‐Quintanilla V, Toriello‐Suárez M, Malet Pintos‐Fonseca A, Sánchez Rodríguez A, Gallo Valentín D, Pascual J. Isolated De Novo Headache as the Presenting Symptom of
Listeria
Meningitis: A Report of 2 Cases. Headache 2020; 60:2573-2577. [DOI: 10.1111/head.13804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Sara Pérez‐Pereda
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
| | - Vicente González‐Quintanilla
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
| | - María Toriello‐Suárez
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
| | | | - Antonio Sánchez Rodríguez
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
| | - Daniel Gallo Valentín
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
| | - Julio Pascual
- Service of Neurology University Hospital Marqués de Valdecilla University of Cantabria and IDIVAL Santander Spain
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36
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Förderreuther S. [Headache emergencies are easily overlooked]. Schmerz 2020; 34:517-524. [PMID: 33118076 DOI: 10.1007/s00482-020-00513-6] [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: 07/21/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 11/26/2022]
Abstract
This article presents secondary headache syndromes caused by life-threatening disease as well as symptomatic headaches requiring immediate treatment to prevent irreversible deficits. Clinical signs and symptoms indicating a secondary headache syndrome are summarized in the so-called SNOOP list (SNOOP: systemic symptoms, neurological symptoms, acute onset, older patients and previous history). The main topic of this publication is the diagnostic procedure, with a discussion of the pitfalls of computed tomography and magnetic resonance imaging investigations and the specificities of other methods such as lumbar puncture and duplex sonography.
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Affiliation(s)
- Stefanie Förderreuther
- Neurologische Klinik, Neurologischer Konsiliardienst am Standort Innenstadt, Ludwig-Maximilians-Universität München, Ziemssenstraße 1, 80336, München, Deutschland.
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García-Azorín D, Abelaira-Freire J, Rodriguez-Adrada E, González-García N, Guerrero ÁL, Porta-Etessam J, Martín-Sánchez FJ. Study about the Manchester Triage System subtriage in patients that visited the Emergency Department due to headache. Neurologia 2020; 38:S0213-4853(20)30275-9. [PMID: 33268106 DOI: 10.1016/j.nrl.2020.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- D García-Azorín
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
| | - J Abelaira-Freire
- Servicio de Emergencias, Hospital Clínico Universitario San Carlos, Madrid, España
| | | | - N González-García
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Á L Guerrero
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Valladolid, España; Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España; Departamento de Medicina, Facultad de Medicina, Universidad de Valladolid, Valladolid, España
| | - J Porta-Etessam
- Unidad de Cefaleas, Servicio de Neurología, Hospital Clínico Universitario San Carlos, Madrid, España; Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, España.
| | - F J Martín-Sánchez
- Servicio de Emergencias, Hospital Clínico Universitario San Carlos, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, España
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Grant R, Dowswell T, Tomlinson E, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Bulbeck H, Kernohan A, Robinson T, Lawrie TA. Interventions to reduce the time to diagnosis of brain tumours. Cochrane Database Syst Rev 2020; 9:CD013564. [PMID: 32901926 PMCID: PMC8082957 DOI: 10.1002/14651858.cd013564.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available. OBJECTIVES To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions. SEARCH METHODS For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014. SELECTION CRITERIA We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author. MAIN RESULTS We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic. AUTHORS' CONCLUSIONS In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.
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Affiliation(s)
- Robin Grant
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - Therese Dowswell
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers, 1st Floor Education Centre, Royal United Hospital, Bath, UK
| | - Paul M Brennan
- Translational Neurosurgery Department, Western General Hospital, Edinburgh, UK
| | - Fiona M Walter
- Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - David William Hunt
- Foundation School/Dept of Clinical and Experimental Medicine, Royal Surrey County Hospital/University of Surrey, Guildford, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings. J Clin Med 2020; 9:jcm9082621. [PMID: 32806717 PMCID: PMC7464980 DOI: 10.3390/jcm9082621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 02/03/2023] Open
Abstract
The aim of this study was to measure prevalence, to describe underlying etiologies, and to assess radiological findings, focusing on significant intracranial abnormality (sICA). This was a prospective study of unselected adult patients admitted to the emergency department (ED) in a tertiary care hospital where all presenters were systematically interviewed about their symptoms. We attributed nontraumatic headache with neuroimaging to four groups: Normal or no new finding, extracranial abnormality, insignificant intracranial abnormality, or significant intracranial abnormality. sICA was defined as “needing acute therapy”, “needing follow-up neuroimaging”, or “clinically important neurological disorder”. Among 11,269 screened ED presentations, the prevalence of nontraumatic headache was 10.1% (1132 patients). Neuroimaging (cCT and/or cMRI) was performed in 303 patients. Seventy (23.1% of scanned; 6.2% of all headache patients) patients had sICA. Etiologies were cerebrovascular disease (56%), intracranial bleeding (17%), tumors (14%), infection (9%), and others (6%). Short-term outcome was excellent, with 99.3% in-hospital survival in patients with and 99.4% in patients without neuroimaging, and 97.1% in sICA; 1-year survival in outpatients with neuroimaging was 99.2%, 99.0% in outpatients without, and 88.6% in patients with sICA. Factors associated with sICA were age, emergency severity index (ESI) of 1 or 2, Glasgow coma score (GCS) under 14, focal neurological signs, and a history of malignancy. Prevalence of headache and incidence of sICA were high, but survival after work-up for nontraumatic headache was excellent in the 94% patients without sICA. Due to the incidence of sICA, extensive indication for neuroimaging in headache patients is further warranted, particularly in patients with risk factors.
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Abstract
PURPOSE OF REVIEW This article reviews treatment options for patients presenting with headache in the emergency department (ED) and for inpatients, including red flags and status migrainosus (SM). RECENT FINDINGS Most patients presenting with headache in the ED will have migraine, but red flags must be reviewed to rule out secondary headaches. SM refractory to home treatment is a common reason for ED presentation or inpatient admission, but high-quality treatment evidence is lacking. Common treatments include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks. Other therapies (e.g., ketamine and lidocaine) are used with limited or inconsistent evidence. There is evidence for inpatient behavioral management therapy. This article details red flags to review in the workup of headache presentation in the ED and provides a step-wise approach to ED and inpatient management. However, more studies are needed to better optimize care.
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Affiliation(s)
- Jennifer Robblee
- Jan and Tom Lewis Migraine Treatment Program, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Kate W Grimsrud
- Cerebrovascular and Hospital Neurology, Penrose Neuroscience, Colorado Springs, CO, USA
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Negro A, Spuntarelli V, Sciattella P, Martelletti P. Rapid referral for headache management from emergency department to headache centre: four years data. J Headache Pain 2020; 21:25. [PMID: 32169031 PMCID: PMC7071765 DOI: 10.1186/s10194-020-01094-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 12/26/2022] Open
Abstract
Background Headache is one of the most common reason for medical consultation to emergency department (ED). The inappropriate use of ED for non-emergency conditions is a problem in terms of overcrowding of emergency facilities, unnecessary testing and treatment, increased medical costs, burden on medical service providers and weaker relationships between patient and primary care provider. The aim of this study was to analyze the different stages of ED management of headache to identify those deficiencies that can be overcome by a fast referral to a headache clinic. Methods The study is a retrospective analysis of the electronic medical records of patients discharged from an academic ED between January 1, 2015 and December 31, 2018 and referred to the tertiary level headache centre of the same hospital. We analyzed all aspects related to the permanence in ED and also assessed whether there was a match between the diagnosis made in ED and ours. Results Among our sample of 244 patients, 76.2% were admitted as “green tag”, 75% underwent a head computed tomography, 19.3% received a neurological consultation, 43% did not receive any pharmacological treatment and 62.7% still had headache at discharge. The length of stay in ED was associated with reporting the first aura ever (p = 0.014) and whether patients received consultations (p < 0.001). The concordance analysis shown a significant moderate agreement only for the diagnosis of migraine and only between triage and headache centre. Conclusions Most patients who went to ED complaining of headache received the same treatment regardless of their diagnosis and in many cases the headache had not yet resolved at the time of discharge. Given the many shortcomings in headache management in ED, rapid referral to the headache centre is of paramount importance to help the patient achieve a definiteve diagnosis and appropriate treatment.
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Affiliation(s)
- Andrea Negro
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy. .,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy.
| | - Valerio Spuntarelli
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Paolo Sciattella
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy.,Regional Referral Headache Centre, Sant'Andrea Hospital, Rome, Italy
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Tension-type headache in the Emergency Department Diagnosis and misdiagnosis: The TEDDi study. Sci Rep 2020; 10:2446. [PMID: 32051440 PMCID: PMC7016102 DOI: 10.1038/s41598-020-59171-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/24/2020] [Indexed: 11/08/2022] Open
Abstract
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.
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Giamberardino MA, Affaitati G, Costantini R, Guglielmetti M, Martelletti P. Acute headache management in emergency department. A narrative review. Intern Emerg Med 2020; 15:109-117. [PMID: 31893348 DOI: 10.1007/s11739-019-02266-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
Headache is a significant reason for access to Emergency Departments (ED) worldwide. Though primary forms represent the vast majority, the life-threatening potential of secondary forms, such as subarachnoid hemorrage or meningitis, makes it imperative for the ED physician to rule out secondary headaches as first step, based on clinical history, careful physical (especially neurological) examination and, if appropriate, hematochemical analyses, neuroimaging or lumbar puncture. Once secondary forms are excluded, distinction among primary forms should be performed, based on the international headache classification criteria. Most frequent primary forms motivating ED observation are acute migraine attacks, particularly status migrainous, and cluster headache. Though universally accepted guidelines do not exist for headache management in an emergency setting, pharmacological parenteral treatment remains the principal approach worldwide, with NSAIDs, neuroleptic antinauseants, triptans and corticosteroids, tailored to the specific headache type. Opioids should be avoided, for their scarce effectiveness in the acute phase, while IV hydration should be limited in cases of ascertained dehydration. Referral of the patient to a Headache Center should subsequently be an integral part of the ED approach to the headache patients, being ascertained that lack of this referral involves a high rate of relapse and new accesses to the ED. More controlled studies are needed to establish specific protocols of management for the headache patient in the ED.
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Affiliation(s)
- Maria Adele Giamberardino
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Giannapia Affaitati
- Headache Center, Geriatrics Clinic, Department of Medicine and Science of Aging and Ce.S.I.-Met, G. D'Annunzio University of Chieti, 66100, Chieti, Italy
| | - Raffaele Costantini
- Institute of Surgical Pathology, G. D'Annunzio University of Chieti, Chieti, Italy
| | - Martina Guglielmetti
- Department of Clinical Pathology, University of Sassari, Sassari, Italy
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy
| | - Paolo Martelletti
- Department of Clinical and Molecular Medicine, Sapienza University, Via di Grottarossa, 1035, 00189, Rome, Italy.
- UOC Medicina Interna, AOU Sant'Andrea, Rome, Italy.
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Miller AC, K Pfeffer B, Lawson MR, Sewell KA, King AR, Zehtabchi S. Intravenous Magnesium Sulfate to Treat Acute Headaches in the Emergency Department: A Systematic Review. Headache 2019; 59:1674-1686. [PMID: 31566727 DOI: 10.1111/head.13648] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Non-traumatic headaches comprise up to 4% of all emergency department (ED) visits. Current practice is moving toward multimodal analgesia regimens that limit narcotic use. OBJECTIVE The objective of this systematic review is to address the following research question: In patients with non-traumatic headaches (Population), does administration of intravenous magnesium sulfate (Intervention) compared to placebo, corticosteroids, dopamine antagonists, ergot alkaloids, non-steroidal anti-inflammatory drugs (NSAIDs), triptans, or usual care result in better pain control, lower rate of recurrence at 24 hours, lower requirements for rescue analgesia, and less adverse medication effects (Outcomes)? METHODS Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Inclusion criteria were: (1) randomized clinical trial (RCT), (2) patients age ≥18 years, (3) non-traumatic headache, (4) patients treated in ED or an outpatient acute care treatment center, and (5) magnesium sulfate administered intravenously (IV). Eligible comparison groups included: placebo, conventional therapy, dopamine antagonist, NSAID, corticosteroid, ergot alkaloid, or triptans. RESULTS Out of 4018 identified references, 7 RCTs (545 participants) that treated migraine headaches (n = 6) and benign non-traumatic headaches (n = 1) met inclusion criteria. Pain intensity was improved with magnesium sulfate vs comparators at 60-120 minutes, but not at earlier time points. Result for the endpoint of pain reduction by 50% were conflicting as 3 studies reported that headache was improved, unchanged, and less with magnesium sulfate. Complete pain relief was improved with magnesium sulfate in 1 study, and in the migraine with aura (MA) subgroup in another. The need for rescue analgesia at any point was improved with magnesium sulfate in 1 study, and in the MA subgroup in another. Twenty-four-hour headache recurrence was improved with magnesium sulfate in 1 study, but unchanged in a second. The intended meta-analysis was not performed due to the clinical heterogeneity among studies. CONCLUSION While we cannot draw a firm conclusion on the efficacy or benefit of intravenous magnesium sulfate in the treatment of acute non-traumatic headaches, the existing evidence indicates potential benefits in pain control beyond 1 hour, aura duration, and need for rescue analgesia.
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Affiliation(s)
- Andrew C Miller
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Brandon K Pfeffer
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Michael R Lawson
- Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Kerry A Sewell
- William E. Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Alexandra R King
- Emergency Medicine and Toxicology, Vidant Medical Center, Greenville, NC, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY, USA
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