Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology

Gilbert, Jane; Johnson, Kevin; Larkin, Gregory Luke; Moore, Christopher L.

doi:10.1136/emermed-2011-200088

Cited by 71 publications

(56 citation statements)

References 22 publications

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“…An increased number of abnormal fundus findings among younger headache patients also stresses the independent relevance of the ocular fundus examination in the evaluation of headache patients, because it runs counter to the overall trend of secondary headache occurring more frequently in older patients. 4,24 The largest group of optic nerve abnormalities detected (36%) constituted isolated retinal hemorrhages. If we presume that the majority of these were secondary to hypertension, 25,26 and combine them with the 14% of the abnormal fundi with grade III/IV hypertensive retinopathy, then approximately half of the headache patients with abnormal ocular fundi had findings attributable to hypertension.…”

Section: Resultsmentioning

confidence: 99%

Nonmydriatic ocular fundus photography among headache patients in an emergency department

et al. 2013

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Objectives: Determine the frequency of and the predictive factors for abnormal ocular fundus findings among emergency department (ED) headache patients.Methods: Cross-sectional study of prospectively enrolled adult patients presenting to our ED with a chief complaint of headache. Ocular fundus photographs were obtained using a nonmydriatic fundus camera that does not require pupillary dilation. Demographic and neuroimaging information was collected. Photographs were reviewed independently by 2 neuroophthalmologists for findings relevant to acute care. The results were analyzed using univariate statistics and logistic regression modeling. Results:We included 497 patients (median age: 40 years, 73% women), among whom 42 (8.5%, 95% confidence interval: 6%-11%) had ocular fundus abnormalities. Of these 42 patients, 12 had disc edema, 9 had optic nerve pallor, 6 had grade III/IV hypertensive retinopathy, and 15 had isolated retinal hemorrhages. Body mass index $35 kg/m 2 (odds ratio [OR]: 2.3, p 5 0.02), younger age (OR: 0.7 per 10-year increase, p 5 0.02), and higher mean arterial blood pressure (OR: 1.3 per 10-mm Hg increase, p 5 0.003) were predictive of abnormal retinal photography. Patients with an abnormal fundus had a higher percentage of hospital admission (21% vs 10%, p 5 0.04). Among the 34 patients with abnormal ocular fundi who had brain imaging, 14 (41%) had normal imaging.Conclusions: Ocular fundus abnormalities were found in 8.5% of patients with headache presenting to our ED. Predictors of abnormal funduscopic findings included higher body mass index, younger age, and higher blood pressure. Our study confirms the importance of funduscopic examination in patients with headache, particularly in the ED, and reaffirms the utility of nonmydriatic fundus photography in this setting. In the emergency department (ED), headache is the fourth most common chief complaint among all patients and the single most common neurologic chief complaint.1 More than 3 million ED visits for headache occurred in the United States during 2008, 2 and it is estimated that 3% to 5% of the general population has visited an ED for headache.3 The vast majority of these headaches are primary, requiring only symptomatic relief. 2,4,5 However, approximately 2% of all patients with headache and more than 18% of patients with sudden, severe headaches have a serious underlying cause. 4,[6][7][8][9] The frequency of secondary headaches also increases with age, occurring in almost 15% of headache sufferers older than 75 years. 4 The ED physician has the difficult task of discriminating between nonemergent headaches and those requiring acute care. Examination of the ocular fundus is one aspect of the physical examination that helps screen for potential "red flags," such as papilledema, that suggest a more ominous cause of headache.10,11 Unfortunately, funduscopy, performed infrequently in acute care settings such as the ED, is also not accurately interpreted by nonophthalmology personnel. 10 Our goal was to

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Section: Resultsmentioning

confidence: 99%

Nonmydriatic ocular fundus photography among headache patients in an emergency department

et al. 2013

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“…It is unknown whether ED diagnostic testing for headache differs by sex, but this is a direction for future research, especially considering the increase in imaging for atraumatic headache in recent years. 74 Another aspect of acute headache pertinent to emergency physicians relates to the use of health care resources, specifically ED visits. Women are approximately three times more likely than men to visit the ED for acute headache and almost five times more likely than men to visit the ED for migraine specifically.…”

Section: Epidemiology/outcomesmentioning

confidence: 99%

Gender Differences in Neurologic Emergencies Part I: A Consensus Summary and Research Agenda on Cerebrovascular Disease

Madsen

Seigel²,

Mackenzie

et al. 2014

Acad Emerg Med

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Cerebrovascular neurologic emergencies including ischemic and hemorrhagic stroke, subarachnoid hemorrhage (SAH), and migraine are leading causes of death and disability that are frequently diagnosed and treated in the emergency department (ED). Although sex and gender differences in neurologic emergencies are beginning to become clearer, there are many unanswered questions about how emergency physicians should incorporate sex and gender into their research initiatives, patient evaluations, and overall management plans for these conditions. After evaluating the existing gaps in the literature, a core group of ED researchers developed a draft of future research priorities. Participants in the 2014 Academic Emergency Medicine consensus conference neurologic emergencies working group then discussed and approved the recommended research agenda using a standardized nominal group technique. Recommendations for future research on the role of sex and gender in the diagnosis, treatment, and outcomes pertinent to ED providers are described for each of three diagnoses: stroke, SAH, and migraine. Recommended future research also includes investigation of the biologic and pathophysiologic differences between men and women with neurologic emergencies as they pertain to ED diagnoses and treatments.ACADEMIC EMERGENCY MEDICINE 2014;21:1403-1413 by the Society for Academic Emergency Medicine C erebrovascular neurologic emergencies such as ischemic and hemorrhagic stroke, subarachnoid hemorrhage (SAH), and migraine are among the most lethal and disabling conditions presenting to the emergency department (ED). We have made great strides in understanding and treating these conditions, and our efforts have led to improved outcomes for these patients. Sex-and gender-based distinctions, however, are only recently becoming clearer, and much work is needed to explain the differences observed between men and women. After a focused review of the current literature on preclinical, clinical, and outcomes differences between women and men, and then the consensus process, we propose a research agenda in the areas of stroke, SAH, and headache/migraine. METHODSAfter evaluating the current literature, the authors, all emergency medicine (EM) researchers, proposed an agenda for future research. Consensus was reached using an iterative process through the four-part nominal group technique as already described in the executive summary. 1 A multidisciplinary group of participants (EM, critical care medicine, internal medicine, physical and rehabilitation medicine) prioritized the final iteration of themes/questions using the Poll Everywhere Web-based voting method. Descriptive statistics were calculated to tabulate the final list of questions presented below. The proposed research questions were then discussed and voted on by participants in the Academic Emergency Medicine consensus conference neurologic emergencies working group (see footnote for listing) at the meeting in May 2014. STROKE Epidemiology/OutcomesStroke is the fourth leading ca...

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“…Headache is one of the most common complaints in the ED, accounting for approximately 1-3% of all visits [5]. The use of neuroimaging as part of the initial workup in the ED for patients with atraumatic headache is increasing, while the proportion of visits in which intracranial pathology of clinical significant was diagnosed by imaging decreased, suggesting an overuse of this diagnostic modality [5].…”

Section: Introductionmentioning

confidence: 99%

Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

2018

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Introduction: The use of neuroimaging as part of the initial workup in the emergency department (ED) for patients with atraumatic headache is increasing, whereas the proportion of cases in which clinically significant intracranial pathology is detected is decreasing. In the last few decades, the exposure to medical ionized radiation from utilization of computer tomography (CT) increased dramatically, raising concern about radiation-induced cancer. Different guidelines were suggested to address the role of neuroimaging in the investigation of adult patients presenting to the ED with nontraumatic headache. Materials and Methods: We retrospectively evaluated data from all consecutive patients who underwent a head CT in the ED for the evaluation of headache during 2015. Patients were included only if a normal neurologic examination was documented. Results: In total, 422 patients were included. About 43.4% of scans were normal. Most abnormal findings were sinusitis (148 patients, 35%) or ischemic changes. Seven CT scans (1.6%) showed clinically significant findings requiring an immediate change in management. Conclusion: A normal neurologic examination, even when performed by a neurologist, does not rule out a significant secondary cause for headache. A CT scan in the ED is indicated for patients presenting with severe nonremitting headache who never had neuroimaging in the past.

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Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology

Abstract: The use of CT/MRI for evaluation of atraumatic headache increased dramatically in EDs in the USA between 1998 and 2008. The prevalence of ICP among patients who received CT/MRI declined concurrently, suggesting a role for clinical decision support to guide more judicious use of imaging.

Cited by 71 publications

References 22 publications

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Gender Differences in Neurologic Emergencies Part I: A Consensus Summary and Research Agenda on Cerebrovascular Disease

Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

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