THE CLINICAL APPROACH TO HEADACHE IN THE EMERGENCY DEPARTMENT AND A COST ANALYSIS OF HEADACHE IN THE EMERGENCY MEDICINE SETTING Текст научной статьи по специальности «Клиническая медицина»

Received: 25 February 2021 / Accepted: 08 May 2021 / Published online: 30 June 2021

DOI 10.34689/SH.2021.23.3.009 UDC 614.2:614.88

THE CLINICAL APPROACH TO HEADACHE IN THE EMERGENCY DEPARTMENT AND A COST ANALYSIS OF HEADACHE IN THE EMERGENCY MEDICINE SETTING

Kaan Qelik1, Cemil Kavalci2

1 Bolu izzet Baysal University Faculty of Medicine, Emergency department, Turkey

2 Antalya Training and Research Hospital, Emergency department, Turkey

Abstract

Relevance. Headaches are among the most common causes for emergency department (ED) referrals. The aim of the present study was to analyze and review the costs of the patients who referred to ED due to headache. Materials and methods. This study was conducted prospectively with patients who have referred because of headache between September, 1, 2017 and December, 31, 2017 (3 months. Age, gender, educational status, characteristics, smoking status and alcohol use, comorbidities, predisposing factors, headache characteristics, additional symptoms, physical examination findings, vital parameters, examinations ordered, and cost analysis were performed. The patients were divided into two groups as primary and secondary headache. The differences between Primary headache (PHA) and Secondary headache (CHA) of these data were evaluated.

Results. The median age of the patients was 40 (IQR:22) years;67.3% of the patients were female. The rate of the patients with PHA was 73.3% whereas 26.7% of the patients were SHA. The median age of the patients with SHA was detected higher than the patients with PHA (p<0.05). There was not any difference for gender, occupation, and social habits (p>0.05). Coronary artery disease (CAD), malignancy and chronic obstructive pulmonary disease (COPD)/asthma prevalence were significantly higher in patients with SHA (p<0.05). The frequency of PHA after stress, fatigue, insomnia, increased mental activity and intake of certain foods was detected higher (p <0.05). The prevalence of sudden onset was higher in patients with SHA (p<0.05). Location, characteristics, severity, and duration of the pain were detected similar between both groups (p>0.05). It was determined that overall condition was better in patients with PHA, and the rate of head & neck and neurological conditions was detected higher in patients with SHA (p <0.05). Fever and lower saturation levels were significantly higher in patients with SHA (p<0.05). Pathological findings were detected in 50% of hemogram analyses, 66.7% of blood gas analyses, 41.6% of complete blood count analyses, 75% of direct X-rays, 42.8% of CTs, 75% of 4 diffusion MRIs, and 50% of LP analyses. Mean ED cost of patients with PHA was 2.3 USD (IQR: 1.2USD), and mean ED cost of patients with SHA was 13.3 USD (IQR: 17.5 $). ED cost of patients with SHA was significantly higher than those with PHA (p<0.05).

Conclusion. It was detected that costs of patients whom SHA was considered are higher than those whom PHA was considered. The most significant cause for this depends on the fact that some symptoms and findings exist both in PHA and SHA. We believe that a comprehensive evaluation of these patients may reduce the number of tests and costs accordingly. Key words: Headache, emergency department, cost analysis.

Резюме

КЛИНИЧЕСКИЙ ПОДХОД И АНАЛИЗ ЗАТРАТ НА ПАЦИЕНТОВ С ГОЛОВНОЙ БОЛЬЮ В УСЛОВИЯХ ОТДЕЛЕНИЯ НЕОТЛОЖНОЙ МЕДИЦИНЫ

Каан Челик1, Джемиль Кавальчи2

1 Кафедра неотложной помощи, Медицинский факультет, Университет Болу Иззет Байсал, г. Анталия, Турция

2 Отделение неотложной помощи, Учебно-исследовательская больница Анталии, г. Анталия, Турция

Актуальность. Головная боль является одной из наиболее частых причин обращения в отделение неотложной медицины.

Целью настоящего исследования было проанализировать затраты на обслуживание пациентов, которые обратились в отделение неотложной медицины из-за головной боли.

Материалы и методы. Исследование было проведено проспективно с включением пациентов, которые обратились за помощью из-за головной боли в период с 1 сентября 2017 г. по 31 декабря 2017 г. (3 месяца).

Учитывались возраст, пол, образовательный статус, характеристики, статус курения и употребления алкоголя, сопутствующие заболевания, предрасполагающие факторы, характеристики головной боли, дополнительные симптомы, результаты физикального обследования, жизненно важные параметры, назначенные обследования и анализ затрат. Пациенты были разделены на две группы с первичной и вторичной головной болью. Были оценены различия данных между первичной головной болью (ПГБ) и вторичной головной болью (ВГБ).

Результаты. Средний возраст пациентов составлял 40 лет (IQR: 22) лет; 67,3% пациентов составляли женщины. Удельный вес пациентов с ПГБ составил 73,3%, тогда как 26,7% пациентов были с ВГБ. Средний возраст пациентов с ВГБ был выше, чем у пациентов с ПГБ (p <0,05). Не было установлено различий по полу, роду занятий и социальным привычкам (p> 0,05). Ишемическая болезнь сердца (ИБС), злокачественные новообразования и хроническая обструктивная болезнь легких (ХОБЛ) / астма встречались значительно выше у пациентов с ВГБ (p <0,05). Частота ПГБ была выше после стресса, переутомления, бессонницы, повышения умственной активности и приема определенных продуктов (р <0,05). Внезапное начало было характерно для пациентов с ВГБ (p <0,05). Локализация, характеристики, тяжесть и продолжительность боли были одинаковыми в обеих группах (p> 0,05). Было определено, что общее состояние было лучше у пациентов с ПГБ, а частота черепно-мозговых, шейных и неврологических состояний была выше у пациентов с SHA (p <0,05). Лихорадка и более низкая сатурация были значительно выше у пациентов с ВГБ (p <0,05). Патологические изменения были обнаружены в 50% анализов гемограммы, 66,7% анализов газов крови, 41,6% общих анализов крови, 75% прямых рентгеновских лучей, 42,8% КТ, 75% 4 диффузионных МРТ и 50% ЛП анализы. Средняя стоимость пребывания для пациентов с ПГБ составила 2,3 доллара США (IQR: 1,2 доллара США), а для пациентов с ВГБ она составила 13,3 доллара США (IQR: 17,5 доллара США) (p <0,05).

Заключение: было установлено, что затраты на пациентов, у которых учитывалась ВГБ, выше, чем у пациентов, у которых учитывалась ПГБ. Наиболее значимая причина этого зависит от того факта, что некоторые симптомы существуют как при ПГБ, так и при ВГБ. Мы считаем, что всестороннее обследование этих пациентов может соответственно сократить количество исследований и расходы.

Ключевые слова: головная боль, отделение неотложной помощи, анализ затрат.

Туйшдеме

Ш¥ГЫЛ МЕДИЦИНА Б0Л1МШЕС1 ЖАГДАЙЫНДА БАС АУРУЫ БАР ПАЦИЕНТТЕРГЕ АРНАЛГАН КЛИНИКАЛЫК ТЭС1Л ЖЭНЕ ШЫГЫНДАРДЫ ТАЛДАУ

Каан Челик1,

Джемиль Кавальчи2

1 Шугыл кемек кафедрасы, Медициналык факультет, Университет Болу Иззет Байсал,

Анталия к-, Туркия;

2 Шугыл кемек белiмшесi, Анталияньщ оку- гылыми ауруханасы, Анталия к-, Туркия

бзектшш. Бас ауруы-шугыл медицинальщ кемекке жYгiнудщ жи кездесетЫ себептерЫщ бiрi.

Бул зерттеудщ максаты бас ауруына байланысты жедел медициналык кемекке жYгiнген пациенттерге кызмет керсету шыгындарын талдау болды.

Материалдар мен эд1стер. Зерттеу 2017 жылдыщ 1 кыр^йеп мен 2017 жылдыщ 31 желтоксаны (3 ай) аралыгында бас ауруы салдарынан кемек сураган пациенттердщ катысуымен жYргiзiлдi. Жасы, жынысы, б^м беру жавдайы, сипаттамалары, темею шегу жэне алкогольдi тутыну жавдайы, iлеспе аурулар, алдын-ала болжайтын факторлар, бас ауруыныщ сипаттамалары, косымша белплер, физикалык емтихан н8тижелерi, емiрлiк ма^ызды параметрлер, тагайындалган емтихандар ж8не шыгындарды талдау ескерiлдi. Наукастар Yнемi ж8не кайталама бас ауруы бар ею топка белiндi. Yнемi бас ауруы ^БА) мен уакытша бас ауруы (УБА) арасындагы м8лiметтер арасындагы айырмашылыктар багаланды.

Нэтижелер1. Пациенттердщ орташа жасы 40 жасты (IQR: 22) курады; пациенттердщ 67,3% - ын 8йелдер курады. YБА бар пациенттердщ Yлес салмагы 73,3% - ды курады, ал пациенттердщ 26,7% - ы УБА-мен болган. УБА бар пациенттердщ орташа жасы YБА (p <0,05) бар пациенттерге караганда жогары болды. Жынысы, к8^ ж8не 8леуметтiк 8деттерi бойынша айырмашылыктар аныкталган жок (p> 0,05). ЖYректщ ишемиялык ауруы (ЖИА), катерлi iсiктер ж8не екпенщ созылмалы обструктивтi ауруы (©СОА) / демкпе УБА (p <0,05) бар пациенттерде айтарлыктай жогары кездескен. PGB житИ стресстен, шамадан тыс жумыстан, уйкысыздыктан, акыл-ой белсендiлiгiнiк жогарылауынан ж8не белг^ бiр тагамдарды кабылдаганнан кейiн жогары болды (p <0,05). Кенеттен басталуы УБА (p <0,05) бар пациенттерге т8н болды. Ауырсыну локализациясы, сипаттамалары, ауырлыгы ж8не узактыгы екi топта да бiрдей болды (p> 0,05). YБА-мен ауыратын наукастарда жалпы жавдай жаксырак екендiгi аныкталды, ал бас сYЙек-ми, жатыр мойны ж8не неврологиялык жавдайлар SHA (p <0,05) пациенттерще жогары болды

УБА (р <0,05) бар пациенттерде кызба ж8не теменп сатурация айтарлыктай жогары болды. Патологиялык езгерютер гемограмма талдауларыныщ 50% - ында, кан газдарыныщ талдауларыныщ 66,7% - ында, жалпы кан талдауларыныщ 41,6% - ында, шелей рентген сэулелерЫщ 75% - ында, КТ-ныщ 42,8% - ында, диффузиялык МРТ-ньщ 75% - ында ж8не ЛП-ньщ 50% - ында аныкталды. YБА бар пациенттер Yшiн болудыщ орташа куны 2,3 А^Ш долларын (ЮР: 1,2 А^Ш доллары), ал УБА бар пациенттер Yшiн ол 13,3 А^Ш долларын (IQR: 17,5 А^Ш доллары) (р <0,05) курады.

Корытынды: УБА есепке алынган Пациенттерге арналган шыгындар YБА есепке алынган пациенттерге караганда жогары екендiгi аныкталды. Муныщ еч ма^ызды себебi кейбiр белплердщ YБА-да да, УБА-да да болатындыгына байланысты. Бiз бул наукастарды жан-жакты тексеру с8йкесiнше зерттеулер мен шыгындарды азайтуы мYмкiн деп санаймыз.

ТYйiндi свздер: Бас ауруы, Жедел ж8рдем белiмшесi, Шыгындарды талдау.

Bibliographic citation:

Celik K., Kavalci C. The clinical approach to headache inthe emergency department and a cost analysis of headache in the emergency medicine setting // Nauka i Zdravookhranenie [Science & Healthcare]. 2021, (Vol.23) 3, pp. 78-86. doi 10.34689/SH.2021.23.3.009

Челик К., Кавальчи Дж. Клинический подход и анализ затрат на пациентов с головной болью в условиях отделения неотложной медицины // Наука и Здравоохранение. 2021. 3(Т.23). С. 78-86. doi 10.34689/SH.2021.23.3.009

Челик К., Кавальчи Дж. Шугыл медицина бeлiмшесi жавдайында бас ауруы бар пациенттерге арналган клиникальщ тэст жэне шыгындарды талдау // Гылым жэне Денсаульщ са^тау. 2021. 3 (Т.23). Б. 78-86. doi 10.34689/SH.2021.23.3.009

Introduction

Headache (HA) has an important place among referrals to emergency department (ED) with an incidence of 1% to 16% among all ED referrals [10, 22, 21]. Although there are hundreds of causes for headache, 98% of these are benign [22, 6]. Remaining 2% may cause severe mortality and morbidity (2, 4).

HAs are divided into two groups as primary headache (PHA) and secondary headache (SHA). A significant pathology may underlie in SHA (intracranial hemorrhage, stroke, and meningitis/encephalitis). PHAs are the remaining headaches after exclusion of SHAs (migraine, cluster and tension), and they do not require urgent intervention. However, type of PHA should be detected, and treatment should be provided [6].

Costs of advanced tests may cause a dilemma in physicians due to the risk of missing SHAs in the ED. However, exclusion of life threatening SHAs is the actual focus point of evaluation of AS. During the evaluation, detailed questioning of the past, pain characteristics and physical examination are essential [6].

Although the use of brain tomography (CT) and magnetic resonance (MRI) has increased dramatically over the years, it was observed that the follow-up period of patients is shortened [9]. However, majority of SHAs are diagnosed in the ED [2].

The aim of the present study was to analyze and review the costs of the patients who referred to ED due to headache.

Material and method

This study was conducted prospectively with patients who have admitted to emergency department of Bolu Izzet Baysal Faculty of Medicine because of headache between October, 1, 2017 and December, 31, 2017 (3 months).

Patients were classified according to the criteria of the 3rd International Classification of Headache Diseases [28]. Age, gender, educational status, characteristics, smoking status and alcohol use, comorbidities, predisposing factors, headache characteristics, additional symptoms, physical examination findings, vital parameters, examinations ordered, and cost analysis were performed. The patients were divided into two groups including PHA and SHA. Differences of the variables between the groups were evaluated.

The study included adult, non-pregnant patients with GCS >14 whose file information was accessed.

Minor patients, patients with history of trauma within last 3 months or pregnant patients, patients whose files were not accessed or deficient were excluded.

The study data were recorded in the computer and evaluated through SPSS (Statistical Package for Social Sciences) Windows 22.0 program. Median, interquartile range (IQR), number of cases and percentile were used to display descriptive statistics. The distribution of the data was evaluated by Kolmogorov Smirnov test. Analysis of non-parametric data between groups was performed through Mann Whitney-U test and categorical variables analysis was conducted with Pearson chi-square test. Results were evaluated at a p value below 0.05 within a confidence interval of 95%.

Results

The median age of the patients was 40 (IQR:22) years;67.3% of the patients were female. One hundred and ten patients (73.3%) were evaluated as PHA whereas 40 (26.7%) patients were evaluated as SHA. The most common cause for PHA was migraine (68.2%), and the most common cause for SHA was respiratory tract infections (60%) (Table 1).

Table 1.

Headache classification.

Primary headache (n:110)

Secondary headache (n:40)

Diagnosis

Migraine

Tension type headache (TTH) Cluster headache (TTH) Unclassified

Respiratory Tract infections ischemic stroke Hypertension

Corbonmonoxide poisoning

Hyponatremia

Encephalitis

Hemorrhagic stroke_

N

75 28

5 2

24

6 4 2 1 1 2

%

68.2 25.5 4.5 1.8 60.0 15.0 10 5.0 2.5 2.5 5.0

The median age of the patients with SHA was significantly higher than the patients with PHA (p<0.05) in our study. There was not any difference for gender, occupation, and social habits (p>0.05). Coronary artery

disease (CAD), malignancy and chronic obstructive pulmonary disease (COPD)/asthma prevalence were significantly higher in patients with SHA (p<0.05) (Table 2).

Comparison of sociodemographic characteristics and co-morbidities with headache type.

Total (n:150)

Primary headache (n:110)

Secondary headache (n:42)

Table 2.

Age (years), Median (IQR)

40 (27)

38 (26)

47.5 (34)

0.016

Gender,

Male

49 (32.7)

35 (31.8)

14 (35)

Female

101 (67.3)

75 (68.2)

26 (65)

0.713

Profession, n(%) Working

54 (36)

41 (37.3)

13 (32.5)

Not working

96 (64)

69 (62.7)

27 (67.5)

0.590

Education,

Literate

4 (2.7)

2 (1.8)

2 (5)

Elementary school

62 (41.3)

45 (40.9)

17 (42.5)

High school

38 (25.3)

28 (25.5)

10 (25)

University

46 (30.7)

35 (31.8)

11 (27.5)

0.768

Habits, n(%)

Smoking

37 (24.7)

31 (28.2)

6 (15)

Alcohol

4 (2.7)

4 (3.6)

0.098

0.222

Comorbidities, n(%) Hypertension

31 (20.7)

21 (19.1)

10 (25)

Diabetes mellitus

10 (6.7)

6 (5.5)

4 (10)

Collagen tissue disease

21 (14)

14 (12.7)

7 (17.5)

Coronary artery disease

9 (6)

3 (2.7)

6 (15)

Asthma/COPD

8 (5.3)

3 (2.7)

5 (12.5)

Malignancy

4 (2.7)

1 (0.9)

3 (7.5)

Hematological diseases

4 (2.7)

2 (1.8)

2 (5)

Chronic renal failure

2 (1.3)

1 (0.9)

1 (2.5)

Other

17 (11.3)

12 (10.9)

5 (12.5)

0.429

0.324

0.456

0.005

0.018

0.029

0.289

0.453

0.786

IQR: Interquartile range, COPD: chronic obstructive pulmonary disease

The frequency of PHA after stress, fatigue, insomnia, increased mental activity and intake of certain foods was detected higher (p <0.05). The prevalence of sudden onset was higher in patients with SHA (p<0.05). Location, characteristics, severity, and duration of the pain were detected similar between both groups (p>0.05). There was not any difference for symptoms (p>0.05). It was determined that overall condition was better in patients with

PHA, and the rate of head & neck and neurological conditions was detected higher in patients with SHA (p <0.05). Fever and lower saturation levels were significantly higher in patients with SHA (p<0.05). In our study, mean ED cost of patients with PHA was 2.3 USD (IQR: 1.2USD), and mean ED cost of patients with SHA was 13.3 USD (IQR: 17.5 $). ED cost of patients with SHA was significantly higher than those with PHA (p<0.05) (Table 3).

p

0

Table 3.

Comparison of predisposing factors, pain characteristics, additional symptoms, vital signs, physical examination, and cost with pain type._

Tntal Primary Secondary

headache headache p

(n:150) (n:110) (n:42)

Predisposing factors, n(%) Fasting 41 (27.3) 31 (28.2) 10 (25) 0.699

Stress 91 (60.7) 73 (66.4) 18 (45) 0.018

Fatigue 41 (27.3) 35 (31.8) 6 (15) 0.041

Insomnia 69 (46) 59 (53.6) 10 (25) 0.002

Menstrual cycle 18 (12) 17 (15.5) 1 (2.5) 0.031

Increased Physical Activity 27 (18) 22 (20) 5 (12.5) 0.290

Increased Mental Activity 23 (15.3) 21 (19.1) 2 (5) 0.034

Foods 11 (7.3) 11 (10) 0 0.038

Pain Characteristics, n(%) Initial Sudden 66 (44) 43 (39.1) 23 (57.5) 0.045

Slow 84 (56) 67 (60.9) 17 (42.5)

Location Nape 33 (22) 26 (23.6) 7 (17.5) 0.827

Frontal 2 (1.3) 2 (1.8) 0

Eyes 13 (8.7) 9 (8.2) 4 (10)

Temple 1 (0.7) 1 (0.9) 0

Unilateral 42 (28) 31 (28.2) 11 (27.5)

Common 59 (39.3) 41 (37.3) 18 (45)

Characteristics Stinging 12 (8) 8 (7.3) 4 (10) 0.618

Compressing 36 (24) 24 (21.8) 12 (30)

Burning 11 (7.3) 9 (8.2) 2 (5)

Throbbing 91 (60.7) 69 (62.7) 22 (55)

Severity Mild 9 (6) 7 (6.4) 2 (5) 0.366

Moderate 50 (33.3) 40 (36.4) 10 (25)

Severe 91 (60.7) 63 (57.3) 28 (70)

Duration Minutes 10 (6.7) 10 (9.1) 0 0.143

Days 56 (37.3) 40 (36.4) 16 (40)

Hours 84 (56) 60 (54.5) 24 (60)

Additional symptoms, n(%) Nausea 91 (60.7) 66 (60) 25 (62.5) 0.782

Dizziness 48 (32) 31 (28.2) 17 (42.5) 0.096

Vomiting 44 (29.3) 33 (30) 11 (27.5) 0.766

Syncope 5 (3.3) 2 (1.8) 3 (7.5) 0.086

Fever 24 (16) 16 (14.5) 8 (20) 0.420

Photophobia 72 (48) 49 (44.5) 23 (57.5) 0.160

Fonophobia 55 (36.7) 41 (37.3) 14 (35) 0.798

Ipsilateral myosis 3 (2.7) 3 (2.7) 0 0.291

Ipsilateral pitosis 5 (3.3) 3 (2.7) 2 (5) 0.493

Ipsilateral sweating 5 (3.3) 3 (2.7) 2 (5) 0.493

Eyelid edema 6 (4) 5 (4.5) 1 (2.5) 0.572

Conjunctival bleeding 1 (0.7) 1 (0.9) 0 0.545

Lacrimation 11 (7.3) 10 (9.1) 1 (2.5) 0.171

Nasal Congestion 8 (5.3) 7 (6.4) 1 (2.5) 0.352

Physical examination, n(%) Overall status Well 141 (94) 106 (96.4) 35 (87.5) 0.043

Moderate 9 (6) 4 (3.6) 5 (12.5)

Head & Neck 21 (14) 3 (2.7) 18 (45) <0.001

Respirator system 18 (12) 11 (10) 7 (17.5) 0.211

Cardiovascular System 3 (2.0) 3 (2.7) 0 0.291

central nervous system 3 (2.0) 0 3 (7.5) <0.001

Limbs 3 (2.0) 1 (0.9) 2 (5) 0.114

Vital parameters, Median (IQR) Systolic blood pressure, (mmHg) 128 (23) 128 (22) 128.5 (28) 0.817

Diastolic blood pressure, (mmHg) 80 (17) 82 (16) 77.5 (13) 0.099

Pulse (beat/min) 85 (22) 85 (23) 82.5 (22) 0.481

Saturation, (%) 97 (3) 98 (2) 96 (2) 0.001

Fever, (OC) 36.7 (0.38) 36.6 (0.3) 36.8 (0.8) 0.022

Cost ($), Median (IQR) 2.4 (3.1) 2.3 (1.2) 13.3 (17.5) <0.001

Pathology was detected in 50% of 10 hemogram analyses, in 66.7% of 3 blood gas analyses, 41.6% of 12 complete blood count analyses, 75% of 12 direct X-ray analyses, 42.8% of 7 CT scans, 75% of 4 diffusion MRIs, and half of 2 patients who had lumbar puncture (LP).

Discussion

Headache is one of the common reasons for referring to AS, and it is necessary to investigate/exclude the causes of SHA. Failure to detect the actual cause may cause dramatic consequences [8]. Some points detected in anamnesis and physical examination in detecting SBAs was defined as red flags. The presence of advanced age, exertional, positional, sudden, severe (thunder-style), post-traumatic, meningeal irritation findings, fever, neurological abnormalities, and significant comorbidities should suggest the causes of SHA and direct the clinician to investigate [8]. Locker et al. stated that SHA should not be considered in patients below 50 years of age who do not present sudden onset with normal neurological examination [16].

Muron-Ceroz et al. stated that 59.4% of the patients who referred to the emergency department with BA were PHA, and among these PHA causes, the most common cause was migraine, this was followed by tension-type headache (TTH) [21]. Handschin et al. reported that 73% of the patients had PHA; therefore no imaging was performed and the abnormality was significant in two-thirds of those who were imaged. The most common lesion detected was reported as subacute stroke [10]. Mert et al. stated in their study that 27% of the patients who referred to ED had SHA [18]. Acikgoz et al. reported in their study that 58.5% of HAs were GTB, and 41.5% of them were migraine [1]. Friedman et al. reported that 309 of 480 patients with HA had PHA, 60% of these had migraine, 11 % of them had TTH, 1% had trigeminal autonomic HA, and 26% had unclassified HA [7]. §ahin et al. stated that 58.7% of the patients had PHA, the most common cause of PHA was migraine, and the respiratory tract infection was the most common cause for SHA [13]. In the present study, PHA prevalence was detected 73.3%, the most common cause for PHA was migraine, and the most common cause for SHA was respiratory tract infections; ischemia was detected in patients with intracranial lesion. Our data comply with the literature. We believe that all causes of cases with SHA will not be due to intracranial causes. Due to the fact that our study was conducted during the winter period, we think that infections, especially sinusitis, and carbon monoxide poisoning also have caused SHA.

Muron-ceroz et al. expressed in their study that 77.8% of the patients who referred to the emergency department with HA were women and the median age of women was 37.8 years and the median age of men was 40.2 years [21]. It was expressed in the study above that prevalence of ShA increased after 50 years of age [21]. Nevman et al. stated that the risk of SHA is lower in patients who have referred to ED before 55 years of age [22]. Handschin mentioned in their study that the age average of the patients who had significant pathology in patients whom imaging was performed was higher; however, gender is not associated with the severity of the pathology [10]. Mert et al. stated in their study that the average age of patients with SHA was higher in patients who referred to ED and gender was ineffective on the type of HA [18]. In the present study,

prevalence of female patients was detected higher. The age average of patients with PHA was significantly lower; and there was not any difference between the groups for gender. Since prevalence of migraine which is the most common diagnosis group was higher in women, we believe that prevalence of women is higher in our population and the age average is lower due to the lower age average in this group. Furthermore, the fact that stress factors associated with work in the younger population may be related to TTH which is one of the causes of PBA. Higher number of causes for SHA may be associated with advanced age, and the more frequent vascular pathologies such as stroke and intracranial hemorrhage at later ages.

Previous studies stated that social characteristics such as employment status, marriage, smoking and alcohol are not effective on HA [18, 25,11,4]. Davis Martin et al. reported that there is not an exact association between PHA and alcohol use, and alcohol may accelerate HA attacks in some vulnerable individuals [4]. Sirin stated in his study that educational status affects the diagnosis duration in migraine patients [26]. It was expressed that alcohol and smoking are effective on migraine attack [26]. It was detected that education, working status and social habits were ineffective on the type of BA in our study. We believe that although education and work status have an impact on the stress and life of the individual, it does not directly affect the physiology of the pain. We believe that smoking and alcohol do not make a difference between the groups because they are effective on both PHA and SHA.

Although the importance of comorbidity in HA was emphasized by many researchers, it was not used as a classification tool in the differential diagnosis of HA [3,17]. It is expressed that causes of SHA should be focused in case of human immunodeficiency virus (HIV) and malignancy in patients who have referred to ED due to HA [22,6]. Handschin et al. stated in their study that the frequency of malignancy was high in patients with special features in imaging, and other comorbidity and immune system suppression were not associated with the detection of features in imaging [10]. A previous study conducted in our country reported that prevalence of SHA increased by co-morbid factors [18]. It was determined that CAD, malignancy and asthma/COPD increased significantly in patients with SHA, and other comorbid factors were found to be more common in patients with SHA; however, it was not statistically significant. We believe that this condition may be related with the comorbidity that increases with age, and increasing risk factors may lead to intracranial pathologies by increasing vascular pathologies. Furthermore, it should be noted that the comorbidity developing in later ages and the drugs used may have adversely affected the immune system and led to infective causes more frequently.

Stress, fatigue, depression or HAs triggered by hunger are commonly observed in migraine or TTHs [22]. Mert et al. stated in their study that stress factors are lower in patients with SHA [18]. It was stated that stress, mental tension, menstruation, alcohol, climate change, some foods and smoking trigger the attack in migraine patients [13]. Some factors such as hunger and increased physical activity had no effect on the type of HA in our study; however, stress, fatigue, menstrual cycle, increased mental

activity, and some foods were found to be involved in the etiology of PHA prevalence. We believe that stress, fatigue and increased mental activity increase the frequency of TTH whereas stress, menstrual cycle and some foods trigger migraine.

Studies have emphasized that the character of the pain is important for the type of HA. It is stated in aforesaid studies that those with onset, with different severity from previous pain episodes, and with increased frequency and intensity may indicate SBA [22, 6]. Mert et al. reported that the prevalence of unilateral headache is higher in PHA; and SHA is higher on calvarial zone [18]. Handschin et al. stated that the onset, duration and severity of headache were similar between patients with specific and nonspecific features in imaging [10]. Sirin stated in his study that the majority of the patients described the severity of pain as very higher [13]. Migraine is a pathology presenting with attacks of which each attack lasts for 4 to 72 hours [20]. The pain duration in TTH varies between 30 minutes and 7 days. The patient has pain for approximately 15 days in a month and this pain may become continuous over time (11, [14]. In our study, it was found that pain with sudden onset was significantly higher in SBAs; however, but there was not any association between pain type and localization, pain duration, and pain type. We believe that patients who present with PBA may easily describe when and how the pain begins; however, they cannot report the character and localization of the pain. Longer duration of pain (especially migraine) in PHAs and delay in diagnosis of SHA may have caused no difference between the groups. Furthermore, since all individuals with HA defend that their pain is always very severe regardless from the pain type, this might have caused the difference between the groups.

Multiple symptoms such as photophobia, phonophobia or osmophobia in migraine and may be associated with nausea with or without vomiting [22]. Nausea is detected by 90% and vomiting is detected by 30% in migraine patients [27]. Patients with cluster headache experience one or more ipsilateral autonomic symptoms such as lacrimation, conjunctival injection, nasal congestion, ptosis, miosis, eyelid edema and swelling of the forehead [22]. Vomiting is not expected in TTH, and nausea is very rare. It is also known that TTH is associated with stress disorder and this stress is one of the causes of nausea [5]. It was stated that causes of SHA should be considered in patients who have referred to ED due to HA expressing projectile vomiting and systemic pathological findings (fever, neck stiffness, rash) [22, 6]. Munoz-Ceron et al. reported in their study that pain features and other symptoms (diplopia, vertigo and syncope) in PHA and SHA [21]. Handschin et al. stated in their study that there is not any difference between patients with specific and nonspecific imaging characteristics in imaging forfever, cough, exhaustion, fatigue, nausea and vomiting, visual disorder, syncope, headache, physical activity as well as neck stiffness [10]. No association was detected between symptoms and HA type in our study. We believe that there is no significant difference between the groups because some symptoms are observed in both groups (nausea, dizziness, etc.) and some symptoms are rarely observed.

A detailed physical and especially neurological examination should be performed in patients who refer to

ED due to HA. Especially focal neurological deficits may indicate structural brain disease and require neuroimaging [22]. It was stated that the abnormality in neurological examination in patients with HA belongs to SHA [22, 6]. Handschin et al. found that patients with specific CT findings had dizziness, the frequency of pathology was high and the Glasgow Coma Scale (GCS) was lower in their neurological examination [10]. It was shown in a study that abnormal neurological examination, sudden and sleep-onset headache were not statistically significant [21]. It was determined in our study that overall condition was better in patients with PHA, and the frequency of pathology found in head-neck and neurological examination was more pathological in patients with SHA. We believe that patients with intracranial pathology present neurological findings and such pathologies cause deterioration in overall condition depending on affecting many systems by causing imbalance in cytokine and neurotransmitter balance in the brain. Furthermore, we believe that the pathology prevalence in head and neck examination is higher, since respiratory system infections, especially sinusitis, are among the secondary causes.

Locker et al. emphasized that body temperature, blood pressure etc. among vital signs are insufficient to exclude secondary headache [10]. Handschin et al. stated in their study that presence of any feature in imaging are not associated with vital signs (1). In our study, it was found that body temperature was higher, saturation was lower in patients with SHA, and other parameters were similar between the groups. We believe that patients with SHA have higher body temperature and lower saturation due to both intracranial infections and respiratory tract infections. We believe that the values were similar due to the other (blood pressure and pulse rate) affecting both groups at a similar rate.

Although no abnormality was found in approximately 95% of all examinations performed under ED conditions, it was stated that it should be investigated [8]. In a previous study, 3-year CT results of patients who referred due to HA were evaluated and it was reported that serious pathology was detected in 10% of the cases [13]. A previous study reported significantly positive CT findings by 2.2% in patients who referred to the emergency department due to HA [23]. Locker et al. stated in their study that 81.2% of the patients had PHA, 21.8% of all patients needed CT and 6.5% of them needed LP. They stated that 80.5% of the patients who had CT scan were normal, and 78.3% of the patients who had LP were normal. [24). Miller et al. stated that although unnecessary tests were required in cases with HA in ED, these patients were not followed up by increased deaths or missed diagnoses after discharge [19]. Pathological findings were detected in 50% of hemogram analyses, 66.7% of blood gas analyses, 41.6% of complete blood count analyses, 75% of direct X-rays, 42.8% of CTs, 75% of 4 diffusion MRIs, and 50% of LP analyses ordered in our study. Our results show that fewer tests are required and more pathologyis detected compared to the literature. We believe that evaluation of the patients by the emergency specialist, deepening of the anamnesis, complete physical examination and prolonging the patient follow-up period contributed to this result.

There is no need for additional examination in patients with suspected PHA in AS; however; additional tests may be required to find the cause in patients who are suspected to have SHA [19]. It was stated that the cost in cases where imaging to the emergency service was used was approximately 3 times more than the cost of patients who referred to the outpatient clinic with headache; consequently, they emphasized that the examinations requested in ED had limited cost effectiveness [12]. It was stated in a previous study that family physicians also cause an additional financial burden to determine the factors that cause PHA in patients with PHA who are referred to neurology 24]. It was determined in our study that the cost of patients with SHA was higher than patients with PHA. We believe that the cost has increased due to the increase in the frequency of additional examinations in order to determine the etiological factor causing SHA and additional pathologies caused by SHA.

Consequently, it was detected that costs of patients whom SHA was considered are higher than those whom PHA was considered. The most significant cause for this depends on the fact that some symptoms and findings exist both in PHA and SHA. We believe that a comprehensive evaluation of these patients may reduce the number of tests and costs accordingly.

Acknowledgment

Authors' Contributions: All authors were equally involved in the research and writing of this article.

Declaration of conflicting interests: The authors declared no potential conflict of interests in respect of the research, authorship and/or publication of this article.

Funding: There is no financial support and sponsorship.

Publication Information: The results of this study have not been previously published in other journals and are not pending review by other publishers.

References:

1. Agikgoz N.P., ilhan A. ilimizde Geng Eri§kin ve Eri§kin Ya§ Grubu Bireylerde Ba§ Agrisi Karakteristikleri.J Turgut Ozal Med Cent 2013:20(3):232-6.

2. Bahra A., Evans R.W. The Secondary Headaches. SAGE Publications Sage UK: London, England; 2021. pp.56-59

3. Clinch C.R. Evaluation of acute headaches in adults. American family physician. 2001;63(4):685.

4. Davis-Martin R.E., Polk A.N., Smitherman T.A. Alcohol use as a comorbidity and precipitant of primary headache: review and meta-analysis. Current pain and headache reports. 2017;21(10):1-12.

5. Duran A. Psikiyatride ilagla tedavi. i.U. Cerrahpa§a Tip Fakultesi Surekli Tip Egitimi Etkinlikleri 2008 S:275-302.

6. Filler L., Akhter M., Nimlos P., editors. Evaluation and management of the emergency department headache. Seminars in neurology; 2019: Thieme Medical Publishers. p.450

7. Friedman B.W., Hochberg M.L., Esses D., Grosberg B., Corbo J., Toosi B., et al. Applying the International Classification of Headache Disorders to the emergency department: an assessment of reproducibility and the frequency with which a unique diagnosis can be assigned to

every acute headache presentation. Annals of emergency medicine. 2007;49(4):409-19. e9.

8. Giamberardino M.A., Affaitati G., Costantini R., Guglielmetti M., Martelletti P. Acute headache management in emergency department. A narrative review. Internal and emergency medicine. 2020;15(1):109-17.

9. Gilbert J.W., Johnson K.M., Larkin G.L., Moore C.L Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology. Emergency medicine journal. 2012;29(7):576-81.

10. Handschin N., Oppliger M., Brehm A.., Psychogios M., Bonati L., Nickel C.H., et al. Nontraumatic Headache in Adult Emergency Patients: Prevalence, Etiologies, and Radiological Findings. Journal of clinical medicine. 2020;9(8):2621.

11. Johnsen M.B., Winsvold B., B0rte S, Vie G.A., Pedersen L.M., Storheim K., et al. The causal role of smoking on the risk of headache. A Mendelian randomization analysis in the HUNT study. European journal of neurology. 2018;25(9):1148-e102.

12. Jordan Y.J., Lightfoote J.B., Jordan J.E. Computed tomography imaging in the management of headache in the emergency department: cost efficacy and policy implications. Journal of the national medical association. 2009;101(4):331-5.

13. Kahn C.E., Jr., Sanders G.D., Lyons E.A., Kostelic J.K., MacEwan D.W., Gordon W.L. Computed tomography for nontraumatic headache: current utilization and cost-effectiveness. Canadian Association of Radiologists journal = Journal l'Association canadienne des radiologistes. 1993;44(3):189-93

14. Karada§ O. Tension Type Headache: Evaluation of Chronic Type.J Clin Anal Med 2013;4(6): 522-6.

15. Locker T.E., Thompson C., Rylance J., Mason S.M. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache: The Journal of Head and Face Pain. 2006;46(6):954-61.

16. Locker T.E., Thompson C., Rylance J., Mason S.M. The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department. Headache: The Journal of Head and Face Pain. 2006;46(6):954-61.

17. Maizels M. The patient with daily headaches. American family physician. 2004;70(12):2299-306.

18. Mert E, Ozge A., Ta§delen B., Yilmaz A., Bilgin N.G. What clues are available for differential diagnosis of headaches in emergency settings? The journal of headache and pain. 2008;9(2):89-97.

19. Miller D.G., Vakkalanka P., Moubarek M.L., Lee S., Mohr N.M. Reduced Computed Tomography Use in the Emergency Department Evaluation of Headache Was Not Followed by Increased Death or Missed Diagnosis. The western journal of emergency medicine. 2018;19(2):319-26.

20. Mu J., Chen T, Quan S., Wang C., Zhao L., Liu J. Neuroimaging features of whole-brain functional connectivity predict attack frequency of migraine. Human brain mapping. 2020;41(4):984-93.

21. Munoz-Ceron J., Marin-Careaga V., Pena 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.

22. Newman L.C., Lipton R.B.. Emergency department evaluation of headache. Neurologic clinics. 1998;16(2):285-303.

23. Quon J.S., Glikstein R., Lim C.S., Schwarz B.A. Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis. Emergency radiology. 2015;22(5):521-5.

24. Rasmussen B.K., Jensen R., Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. Journal of epidemiology and community health. 1992;46(4):443-6.

25. Roslan M.Z. Relationship Between The Number of Cigarettes Per Day and Caffeine Intake on Headache Intensity in Faculty of Medicine Student Batch 2016 of

Universitas Sumatera Utara. Asian Australasian Neuro and Health Science Journal (AANHS-J). 2020;2(1).

13. §ahin A., Vildan O., Tatli O., Karaca Y, Yaman S.O., Karahan S.C. Acil servise izole ba§ agrisi §ikayetiyle ba§vuran hastalarin ayirici tanisinda iskemi modifiye albumin seviyesinin degeri. Kirikkale Universitesi Tip Fakultesi Dergisi. 2018;20(1):1-7.

26. §irin T.C. Agri Devlet Hastanesine ba§vuran migren hastalarinin klinik ve sosyodemografik ozellikleri. Ege Tip Dergisi. 2017;56(3):128-34.

27. Silberstein S.D. Migraine symptoms: result of a survey of self-reported migraineurs. Headache 1995;35: 387-96.

28. Society HCCotlH. The international classification of headache disorders, (beta version). Cephalalgia. 2013;33(9):629-808.

* Coresponding Author: Cemil Kavalci, Prof. Dr., MD

Antalya Training and Research Hospital, Emergency department, Turkey E-mail: [email protected] Phone: +903122036868