Clinical noteDiagnosticsCanadian Headache Society criteria for the diagnosis of acute migraine headache in the ED—do our patients meet these criteria?
Introduction
Migraine headaches are an incapacitating disease accounting for 2.8 million physician encounters each year [1]. Osterhaus et al [2] estimated that $2 to 17.2 billion dollars are lost in productivity each year secondary to this aliment. ED visits to alleviate such symptoms are common.
The recognized “gold standard” for the diagnosis of a migraine remains the International Headache Society criteria (IHSC) (Fig. 1). Use of the IHSC in emergency medicine was recently endorsed by the American College of Emergency Physicians when it was suggested that emergency physicians follow the guidelines set forth by the Headache Consortium in 2000 [3]. Use of the IHSC has standardized the diagnosis of migraines; however, its clinical relevance with respect to ED therapy remains questionable. Olesen and Lipton [4] notes that these criteria are not based on scientific literature. Furthermore, a recent study at our institution demonstrated that only a minority of patients discharged by emergency physicians with a previous and/or discharge diagnosis of migraine met the IHSC [5].
In 1997, the Canadian Headache Society published a modified version of the IHSC [6] (Fig. 2). These criteria were created following a needs assessment performed by members of the Canadian Headache Society [6]. Adjustments to the diagnosis of migraine without aura included expanding headache duration, more flexible pulsatile symptoms, and adding osmophobia as a possible diagnostic criterion. In addition to the changes made to the IHSC criteria, they suggest adding additional questions to improve pattern recognition of migraine [6].
We suspected that the Canadian Headache Society criteria (CHSC) might allow for broader standardization of patients with vascular-type headaches who present to the ED. The purpose of this study was to compare the frequency for which ED patients with migraine headache met the CHSC vs the IHSC.
Section snippets
Study design
This was a prospective observational study.
Setting
The study was conducted in the Department of Emergency Medicine at Morristown Memorial Hospital, a community-based tertiary care center in northern New Jersey between October 2001 and August 2002. The ED has an annual census of approximately 65 000 visits and has an active academic program and emergency medicine residency. The institutional review board at our institution approved this study before patient enrollment.
Population
We enrolled a convenience sample of
Results
Between October 2001 and August 2002, a total of 189 patients were enrolled. All eligible patients agreed to participate and were surveyed. Mean age of participants was 38 years (±13.7 SD); females comprised the majority of enrollees (69%) and 66% were Caucasian (Table 1).
With respect to historical features, 70 (37%) of patients had previous ED visits for similar headaches. Imaging modalities (ie, head computed tomography scan and/or magnetic resonance imaging) had been performed in 44% of
Discussion
Members of the Canadian Headache Society used a multidisciplinary group reviewing literature and comparing alternative clinical pathways to develop their standard definition of migraine headache. Modifications of the IHSC were intended on improving the reliability of interpretation of the individual diagnostic criteria. The group based their recommendations on the most informative, statistically appropriate references that were available at the time [6].
The first modification pertains to
Limitations and future questions
The major limitation of this study is the potential for selection bias. Enrollment of patients was based on a convenience sample, not a true consecutive series. While on duty, study emergency physician investigators enrolled consecutive patients who were eligible for the study. Work schedules of each varied, including mornings, evenings, and overnight shifts. Therefore, we suspect that our study population sample represented our diverse patient population with headache as a whole.
This study
Conclusion
In our study population, less than half of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and IHSC to standardize ED patients for headache research may be limited. Further modification of the CHSC/IHSC for emergency medicine research should be considered.
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