Short‐term stroke risk after emergency department treat‐and‐release headache visit

Abstract

Objective To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short‐term risk of stroke. Background Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. Methods We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005–2018 and New York 2005–2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat‐and‐release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. Results We identified 1,502,831 patients with an ED treat‐and‐release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29–3.16) or back pain (HR: 4.0; 95% CI: 3.74–4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22–1.78) or back pain (HR: 1.49; 95% CI: 1.24–1.80). Conclusion Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

Risk of Stroke and Myocardial Infarction Among Initiators of Triptans

“…Cerebrovascular events may themselves present primarily as migrainelike headache, and misdiagnosis of transient ischemic attack and minor stroke as migraine in the emergency department setting is not rare . A recent study reported that patients discharged to home from the emergency department with a headache diagnosis have a 3- to 4-fold higher risk of stroke in the following month compared with patients presenting with kidney colic or acute back pain . This higher risk was most pronounced within the first 10 days following discharge.…”

TheInternational Classification of Diseases, 10thEdition, Clinical Modification (ICD-10-CM)Code I16.0 Accurately Identifies Patients with Hypertensive Urgency

“…These diagnostic codes for headache have been previously used in administrative claims research. 9 We selected patients with a primary headache disorder as a comparator since headache complaints are very common in patients with severely elevated blood pressure 6 and patients with headache complaints often have elevated blood pressure. 10 For this study, we only included ED encounters that resulted in discharge to home (ED treat- and-release visit).…”

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

“…A history of HDP and other APOs furthermore should be considered a strong risk factor in the evaluation of a young adult with cardiac or stroke-like symptoms; these symptoms are more likely to be misdiagnosed as mimics (eg, anxiety attack, complicated migraine) in young women. [54][55][56][57] Capturing Hypertension Outside the Primary Care Setting Significant barriers exist in accessing regular primary care postpartum in birthing individuals. Therefore, postpregnancy hypertension may go undiagnosed and untreated until the next pregnancy or years later when end-organ manifestations develop prematurely.…”

“…A history of HDP and other APOs furthermore should be considered a strong risk factor in the evaluation of a young adult with cardiac or stroke-like symptoms; these symptoms are more likely to be misdiagnosed as mimics (eg, anxiety attack, complicated migraine) in young women. 54–57…”