Lost diagnoses in not otherwise specified headache in Emergency Department

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.

Trends in the Management of Headache Disorders in US Emergency Departments: Analysis of 2007–2018 National Hospital Ambulatory Medical Care Survey Data

“…Migraine accounted for one-third of headache-related ED visits, and the subtype of headache was not determined in most of the remaining headache-related ED visits in our study. Consistent with prior studies using the same case definition from ED discharge diagnoses [ 28 , 37 , 38 ], the large proportions of NOS headaches (~64%) observed in our study may indicate the challenges of differentiating subtypes of primary headaches in ED settings because of a lack of comprehensive history for the patients’ headaches and the difficulty in applying ICHD-3 diagnostic criteria of primary headache disorders in ED settings. Vigano et al reclassified most NOS headache diagnoses received in the ED as primary headache disorders when patients were re-examined in a headache unit [ 39 ].…”

Common diagnoses and factors associated with abnormal neuroimaging in headache patients in the emergency department

“…The diagnostic uncertainty and large percentage of headaches labeled as non-specific is another major limitation. Factors that play a role in this have previously been explored by Granto et al 25 who surveyed emergency physicians and concluded that the majority (96%) did not know the ICHD-3 criteria.It appears that the percentage in our study of headaches that were labeled as “non-specific” is similar compared to other studies. 25 – 27 …”

“…Factors that play a role in this have previously been explored by Granto et al 25 who surveyed emergency physicians and concluded that the majority )96%) did not know the ICHD-3 criteria.It appears that the percentage in our study of headaches that were labeled as "non-specific" is similar compared to other studies. [25][26][27] Implications of this study for future practice include the need for further studies about the frequency and types of secondary headaches in Saudi Arabia; particularly to explore the incidence and prevalence of disorders that were surprisingly common in our data such as IIH. Other implication would be to study the economic burden of over investigation headaches especially in the context of government financed healthcare.…”