Beware the patient with a headache in the accident and emergency department.

Fodden, D I; Peatfield, R C; Milsom, P L

doi:10.1136/emj.6.1.7

Cited by 39 publications

(26 citation statements)

References 5 publications

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“…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.…”

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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“…In all other reports, the most frequent ED diagnosis for primary headache was migraine [6, 14–18]. In a nationwide study covering the period between 1992 and 2001 on headache management in US EDs, Goldstein et al [8] reported that the diagnosis of migraine was made in 63.5% of patients who attended the ED suffering from headache.…”

Section: Discussionmentioning

confidence: 99%

Headache patients in the emergency department of a Greek tertiary care hospital

et al. 2009

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The aim of this study was to record the demographic and epidemiological data on adult patients with headache who attend the emergency department (ED) and the diagnoses that made by the neurologists in the ED of a tertiary care hospital in metropolitan Thessaloniki (Greece). In an open prospective study, demographic and epidemiological data were collected on all patients who reported headache (as chief complaint or not) and presented to the ED of Papageorgiou Hospital between August 2007 and July 2008. Headache patients accounted for 1.3% of all ED patients and for 15.5% of patients primarily referred to the ED neurologist. Tension type headache was the most frequent diagnosis, followed by secondary headaches and migraine. The large number of patients without final ED diagnosis and ward admission for further evaluation sheds a light on the immense workload of Greek ED physicians. Furthermore, we found evidence for the misuse of Emergency Medical Services by chronic headache patients. These findings indicate shortcomings in the pre-hospital (primary care) management of headache patients in the Greek National Health System to an extent unreported so far.Electronic supplementary materialThe online version of this article (doi:10.1007/s10194-009-0178-3) contains supplementary material, which is available to authorized users.

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“…The authors comment on the low attendance rate of patients with this problem, but the high incidence of serious pathology detected. 2 If serious pathology is suspected or the diagnosis remains unclear, investigation may be indicated. Edmeads points out that investigation is necessary when the patient complains of the worst headache ever, onset of headache with exertion (more suggestive of SAH or raised intracranial pressure), reduced alertness or cognition, neck not perfectly supple (implying blood or pus in the cerebrospinal fluid (CSF)), any abnormality on examination (including fever), or worsening under observation.…”

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confidence: 99%

Headache management--Are we doing enough? An observational study of patients presenting with headache to the emergency department

Locker

Mason²,

Rigby³

2004

Emergency Medicine Journal

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Objectives: To identify the causes of acute headache presenting to the emergency department (ED), assess the adequacy of history, examination, and investigation, and determine which clinical features are predictive of secondary headache. Method: A retrospective study of alert (GCS>14) patients presenting with headache, to an ED over a one year period. Patients were followed up for three months. The adequacy of history, examination, and investigation were compared with published standards. Analysis using Bayes's theorem determined which clinical features were predictive of secondary headache. Results: Headache in alert patients accounted for 0.5% (n = 353) of new patient episodes, 81.2% (n = 280) of patients had a primary headache disorder. One patient (0.3%) had an adequate history recorded. No patient had a complete examination recorded. Seventy seven (21.8%) patients underwent computed tomography of the head; 80.5% (n = 62) were normal. Lumbar puncture was performed in 23 (6.5%) cases; 18 (78.3%) were normal. A number of clinical features were found to be predictive of secondary headache. Conclusion: Headache is an uncommon symptom in alert patients presenting to the ED. The recorded history, examination, and subsequent investigation do not comply with published standards. A number of predictive features have been identified that may permit the development of a clinical prediction rule to improve the management of this patient group.

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Beware the patient with a headache in the accident and emergency department.

Cited by 39 publications

References 5 publications

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Headache patients in the emergency department of a Greek tertiary care hospital

Headache management--Are we doing enough? An observational study of patients presenting with headache to the emergency department

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