Clinical note
Diagnostics
Canadian Headache Society criteria for the diagnosis of acute migraine headache in the ED—do our patients meet these criteria?

Previous Presentation: ACEP Scientific Assembly, Boston 2003.
https://doi.org/10.1016/j.ajem.2004.03.001Get rights and content

Abstract

Introduction

We previously reported that many patients who present to the ED with “migraine” headache do not meet the International Headache Society criteria (IHSC) for the diagnosis of acute migraine.

Objective

The aim of the study was to compare the frequency for which ED patients with migraine headache meet the Canadian Headache Society criteria (CHSC) vs the IHSC.

Methods

This was a prospective, observational study, performed at a community ED. Consecutive patients who presented to study authors with a chief complaint of headache were enrolled. Historical/clinical data were collected on a standardized form. Ninety-five percent confidence intervals (95% CIs) were calculated and Fisher exact test was used as appropriate.

Results

One hundred eighty-nine patients were enrolled in this study. Mean age was 38 years. Females comprised 69% of patients. Thirty-seven percent of patients had prior ED visits for headaches. A positive family history of migraines was present in 35% of patients. Diagnostic imaging was previously performed in 44 of the enrollees to evaluate the cause of their headaches. A total of 43 (23%) patients had a prior diagnosis of migraine. Overall CHSC was met in 18% of patients, compared with 15% of patients who met IHSC. Discharge diagnosis of migraine was made in 41% of patients. Of these patients, 33% met CHSC and 28% met IHSC (P = .30). For patients with discharge diagnosis of migraine, 33% of females and 36% of males fit CHSC (P = .53), whereas 26% and 36% met IHSC (P = .34), respectively. For patients with a prior diagnosis of migraine, 32% met CHSC and 26% met IHSC (P = .24). Patients with a prior diagnosis of migraine and/or a discharge diagnosis of migraine met CHSC 31% (95% CI, 22%-40%) of the time vs 25% for the IHSC (95% CI, 16%-34%) (P = .26). Four patients without a discharge and/or previous diagnosis of migraine met CHSC; 3 met IHSC.

Conclusions

In our study population, only a minority of patients with headache who have prior diagnosis and/or ED diagnosis of migraine headache met CHSC. The utility of CHSC and/or IHSC to standardize ED patients for headache research may be limited.

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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