Send letter to journal:
Re: RULES FOR HEADACHE IN AN ED

Dear Editor

Headache is a very common presentation in the neurology practice, and one of the most prevalent consultations in the office.Thus, headache clinics and/or sub-specialist neurologists with interest in the headache field become more and more common.

However, in an Emergency Department, things are a lot different from the chronic headache-suffer patient. The guidelines of the International Headache Society, for example, do not help the doctor in an ER.

First of all, if the patient present at the ED with a novel symptom, a headache, and he or she never suffered from this kind of pain, a signal of alarm must ring: accurate anamnesis and clinical and neurological examination must be performed with refinement, even in a complex and movement place. There are also signs of danger, as fever, meningeal signs, papilar edema, etc.

The patient with a previous history of headache, a migraine for example, who presents a new type of pain deserve special care.

And in the emergency situation, to benefit the patient, is no shame to a doctor to rule out organic diseases with a CT, a lumbar puncture and so. If the results become negative and the treatment of the pain results in a good picture that is a good thing!

Economics views of such cases, as the managed care ones, or the simplification of the headaches, the prejudice (“is nothing”,” the patient is creating a pain”, etc.) should be stronger avoided, especially in regard to junior doctors and residents.

Send letter to journal:
Re: Primary Headache Disorder in the Emergency Department

Dear Editor

We read with interest the article by Locker et al [1] as we have recently commenced a study looking at the issue of headache in the emergency department from the perspective of the neurology outpatient clinic. Approximately 20% of patients seen in general neurology outpatient clinics have headache as their principal complaint [2], and the vast majority have primary headache disorders, amenable to diagnosis on the basis of the clinical history. Nonetheless, some of these patients have attended emergency departments, been admitted to hospital, and undergone neuroimaging procedures.

Thus far (16/07/04), of 197 consecutive outpatient referrals seen by one consultant neurologist in 22 general neurology outpatient clinics in three hospitals in northwest England, headache has been the principal complaint in 40 patients (F:M = 26:14) of whom 10 (25%) reported previous attendance(s) at an emergency department because of their headache. Five patients were admitted to hospital, 4 underwent neuroimaging procedures. The final neurological diagnosis, using widely accepted diagnostic criteria, was of primary headache disorder in all patients [3].

These are preliminary data from an ongoing study, but nonetheless corroborate the findings of Locker et al. on primary, as opposed to secondary, headache disorders in the emergency department. How best to manage these patients is uncertain. Ideally, with appropriate diagnosis and advice from a practitioner skilled in the art, such patients should never reach an emergency department, but who that practitioner should be - general practitioner, community pharmacist, neurologist - remains to be determined [4]. Clearly it needs to be someone with both an interest and appropriate training in headache disorders. An increased role for primary care in the management of headache disorders has been proposed [5].

References

(1) Locker T, Mason S, Rigby A. Headache management - are we doing enough? An observational study of patients presenting with headache to the emergency department. Emerg Med J 2004;21:327-32.

(2) Larner AJ. NHS Direct for headache. J Neurol Neurosurg Psychiatry 2003;74:1698.

(3) International Headache Society Classification Subcommittee. International classification of headache disorders, 2nd edition. Cephalalgia 2004;24(suppl1):1-160.

(4) Gahir KK, Larner AJ. What role do community pharmacists currently play in the management of headache? A hospital-based perspective. Int J Clin Pract 2004;57:257-9.