In emergency department settings, using the International Headache criteria 3 (ICHD 3) could help differentiate primary headaches from nonprimary headaches in patients who present with nontraumatic headaches, according to a study published in PLOS One.
Researchers used the ICHD 3 to determine if red flags and green flags could be used to evaluate the main etiologies of headaches in the emergency department. Over a 7-week time period, patients who presented in the emergency department during the day with a chief complaint of a headache were invited to participate in the study. All eligible patients completed a clinical interview and a neurological exam, and then, based on the ICHD 3, were diagnosed with either primary or nonprimary (secondary and neuralgias) headaches. Patients with primary headaches were treated with institutional protocols and then had a 48-hour phone follow-up interview to monitor symptoms. Patients with nonprimary headaches completed further evaluations in the hospital to determine etiology and receive treatment.
Of the 244 patients who presented with headaches,
- 77.8% were women with an average age of 37.8 years old and
- 21.2% were men with an average age of 40.2 years old.
Primary headaches were diagnosed in 59.4% of patients, secondary headaches were diagnosed in 32% of patients, and nonclassified headaches were diagnosed in 8.6% of patients. Migraines with or without aura and status migrainosus (93.7%) were the most common etiology for primary headaches and cervical myofascial pain (29.5%) was the most common etiology for nonprimary headaches. Fulfilling the ICHD 3B criteria (P <.001), having a history of similar episodes (P =.02), and having a history of migraine (P =.03) were associated with a diagnosis of primary headache. Being over the age of 50 (P =.02) or having an immunological disorder (P =.03) were associated with a diagnosis of secondary headache. Limitations of this study included the follow-up interview being completed by phone rather than in a clinic and patients not being enrolled if they presented at the hospital between 7 PM and 7 AM, which could have influenced the proportion of etiologies.
The researchers concluded that in the emergency department, “besides the traditional red flags and clinical scenarios the ICHD should be added to the tools to differentiate primary from non-primary headaches.”
Munoz-Ceron J, Marin-Careaga V, Peña L, Mutis J, Ortiz G. Headache at the emergency room: etiologies, diagnostic usefulness of the ICHD 3 criteria, red and green flags. PLoS One. 2019; 14(1):e0208728