Short-term stroke risk after emergency department treat-and-release headache visit

Ava L Liberman; Cenai Zhang; Richard B Lipton; Hooman Kamel; Neal S Parikh; Babak B Navi; Alan Z Segal; Junaid Razzak; David E Newman-Toker; Alexander E Merkler

doi:10.1111/head.14387

Short-term stroke risk after emergency department treat-and-release headache visit

Headache. 2022 Oct;62(9):1198-1206. doi: 10.1111/head.14387. Epub 2022 Sep 8.

Authors

Affiliations

¹ Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA.
² Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
³ Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA.
⁴ Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
⁵ Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
⁶ Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Abstract

Objective: To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke.

Background: Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error.

Methods: We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities.

Results: We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80).

Conclusion: Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

Keywords: diagnostic error; emergency medicine; headache; stroke.

MeSH terms

Adult
Back Pain
Emergency Service, Hospital
Female
Headache / diagnosis
Headache / epidemiology
Headache / therapy
Hospitalization
Humans
Male
Renal Colic* / diagnosis
Renal Colic* / epidemiology
Renal Colic* / therapy
Retrospective Studies
Stroke* / epidemiology
Stroke* / therapy

Abstract

MeSH terms

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