Lost diagnoses in not otherwise specified headache in Emergency Department

DOI: https://doi.org/10.1007/s13760-021-01687-1

Abstract-Summary 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. 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.

Introduction The diagnostic framework of headache in the ED constitutes a challenge for Emergency Physicians (EPs) and specialist consultants.

4.4 Emergency Department Management

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The prevalence of primary headaches ranges between 1.2 and 2.35% of all visits

in the Italian EDs [395, 402].

The role of specialist consultants to improve diagnostic accuracy of headache in

ED is being debated.

The aim of this study was to examine specialist visits carried out in all the patients discharged from ED with diagnosis of NOS headache and to evaluate dis- crepancies between specialist diagnoses and ED diagnosis at discharge.

Patients and methods We took into account the patients who were discharged to home from our ED with a final diagnosis of NOS headache and who underwent at least one specialist exami- nation in our ED.

To analyze the most common reasons why the EPs do not use the correct diagno- sis of headache in ED, two neurologists experienced in headaches (AG and LDA) structured an anonymized questionnaire assessing the knowledge and the applica- tion of ICHD-3 criteria in ED setting in relation to the presence of specialist consul- tants in ED and the EPs friendliness with medical software.

For each patient, we examined demographic and clinical data, diagnostic proce- dures, specialist examinations, discrepancies between specialists and ED diagnosis at discharge.

We also analyzed the presence at discharge of recommendations of the specialist consultant, of indications to refer to the Headache Centre, and therapeutic prescrip- tions for headache.

Results One hundred and eight subjects underwent a neurological examination (87.1%), while non-neurologist consultants visited 35 patients (28.2%).

About half of the patients evaluated by the neurologist (52.8%) underwent a

cranial CT scan.

A definite diagnosis was made only in 46 (37%) patients, with primary head-

aches being the most frequently identified disorder (25.7%).

Seventy-two patients (58.1%), including all 46 patients with a definite specialist diagnosis and 26 out of the 78 patients with NOS headache, received therapeutic prescription at ED discharge.

All the patients who did not receive any therapy at discharge were referred to the

Headache Centre.

The neurological consultants requested all the diagnostic procedures (tests) rec-

ommended only in those patients who did not receive a precise diagnosis.

Ninety-five cases (76.6%) were referred to the Headache Centre: 83 patients

were referred to it by the neurologist, 12 by the EPs.

Discussion This survey focused on the specialist visits performed in ED in all the patients dis- charged from ED with diagnosis of NOS headache.

The aim was to evaluate the discrepancy between specialists and ED diagnoses at discharge, ED management and therapeutic recommendations provided at

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discharge from ED, and the reasons why the EPs do not use the correct diagnosis of headache analyzing the Emergency Physicians’ knowledge and application of ICHD-3 diagnostic criteria in the ED setting.

124 patients who received at least one specialist visit fulfilled the criteria for NOS headache at ED discharge, most patients (87.1%) received neurological exam- ination at least, 12.9% underwent only other specialist consultation.

Almost all EPs (96%) admitted they did not know ICHD-3 criteria, suggesting this is the cause of the high rate of NOS headache diagnoses in ED and why EPs tend to refer patients to specialist consultants.

Acknowledgement A machine generated summary based on the work of Granato, Antonio; D’Acunto, Laura; Morelli, Maria Elisa; Bellavita, Giulia; Cominotto, Franco; Manganotti, Paolo. 2021 in Acta Neurologica Belgica.

Adherence to guidelines of treatment of non-traumatic headache in the emergency department