Headache diagnosis in an urgency and emergency unit: Public Health Relevance and its relationship with cost

Background Headache is a common symptom that affects a significant portion of the general population. It constitutes a challenge for diagnosis in urgency and emergency care services, due to headache’s clinical variability and diverse possible etiologies, besides the limited time and resources of these facilities. Because of this insufficiency and the potential severity associated with the condition, headaches generate considerable expenditures to health systems, related to both diagnostic discrimination and treatment. Objective Evaluating the diagnostic resources used on headache patients care, as well as its Public Health Relevance and relation to cost in an Emergency and Urgency Care unit. Methods Cross-section study analyzing 450 medical records of patients with headache complaints in the time frame from January 1, 2019, and December 31, 2019. Patients were categorized according to the type of headache (primary and secondary), specialized evaluation, complementary exams used in the diagnosis, hospital observation time, and the final expenditure in each patient’s care. Results The total estimated expenditures related to headache care equaled US$90,855.60 (average US$201.90 per patient). 38.9% of cases corresponded to primary headaches and 31.1% to secondary headaches. 30% of cases could not be classified. The resources utilized for secondary headaches diagnosis differed significantly from those used in primary headache diagnosis. However, the final expenditures were similar to both groups. Conclusion The socio-economic impact caused by headaches is unquestionable. It is a highly frequent symptom and both its etiological distinction and adequate treatment require solid evaluation. Due to the resources spent in its evaluation and monitoring, headaches can be considered a public health problem. Therefore, this study suggests that resources should be allocated in the health education and professional training for the proper conduction of these patients, so that they may benefit from an optimized treatment of their condition without overwhelming the health system. Lígia Barros de Oliveira, R João Pinheiro, 923, ap 502, 36201128, Barbacena-MG, Brazil. ligiabarrosdeoliveira@yahoo. com.br Edited by: Marcelo Moraes Valença


Introduction
H eadache is a universally occurring symptom that affects a significant portion of the general population. In Brazil, the estimated annual headache prevalence is 61.6% among men and 77.8% among women. 1 It is also a frequent occurrence in Emergency Care Units, prompting a high number of consultations.
In Urgency and Emergency Care Units, non-traumatic headache complaints represent from 0.5% to 2.8% of medical care. Despite the apparent low frequency, headaches pose a considerable challenge to these facilities, due both to the high variability of their clinical presentation and the wide range of possible diagnoses, which range from benign conditions to high morbimortality causes, and the time and resources available for proper patient assessment. 2 A Canadian study conducted in the emergency department of a tertiary hospital showed that in 37.5% of neurological cases, a consensus was not reached between the initial emergency care diagnosis and the eventual final diagnosis given by a neurologist.
Among these neurological conditions, primary headaches presented one of the highest dissent rates. 3 A systematic review carried out in 2014 concluded that only 56% of migraine patients, a prevalent type of primary headache, received the correct diagnosis when they sought urgency and emergency services. 4 The principal function of an emergency physician when assessing a patient with headache complaints is to identify life-threatening causes and promptly treating them. Moreover, the physician should provide safe and efficacious treatment for the pain. 2 In order to do so, it is recommended to differentiate primary headaches (recurrent headache crises are the main symptom) from secondary headaches (the headache is a symptom of an underlying systemic or neurological disease). 5 The etiological definition of the secondary headache generally requires a complementary test, which is not the case for primary headaches. 5,6 In this scenario, it is expected that patients presenting secondary headache clinical features represent a higher expenditure of human and material resources for the health system. However, primary headaches generate high costs to the health system. They are also one of the main causes of incapacity in the world. The Brazilian public health system estimated annual expenditures with migraine care equaled US$ 140 million. 7 The evaluated indirect costs related to migraine-related absenteeism and presenteeism equaled US$18.6 billion per year. 8 The Italian National Health System's (NHS) average annual cost related to the handling of patients diagnosed with episodic migraine or chronic migraine at a tertiary referral center for headache, in terms of hospitalizations equaled €28 per patient. 9 This paper aimed at evaluating the diagnosis, the utilized resources, its Public Health Relevance and the associated costs in the care of patients with headache complaints in the Emergency and Urgency Unit of the Dr. José Américo Barbacena City Regional Hospital, which belongs to the FHEMIG network.

Methods
A transversal retrospective cohort study was conducted through the analysis of the medical records of patients treated with headache complaints who were admitted to the emergency department of the Regional Hospital of Barbacena, Minas Gerais, from January 1, 2019, to December 31, 2019.

Patients Selection
The study included all consultations conducted in the Emergency and Urgency Unit of Barbacena City's Dr. José Américo Regional Hospital with an initial headache diagnosis whose registration in the electronic records included the following International Classification of Diseases (ICD-10).

Evaluated Variables
The selected patients were evaluated according to the following: age; sex; initial headache diagnosis according to the ICD-10; specialized evaluation (neurologist); lumbar puncture and CSF analysis realization; head computed tomography (CT); registered final diagnosis; total cost of consultation, discriminating imaging test costs and medication costs (based on documentation provided Headache diagnosis in an urgency and emergency unit: Public Health Relevance and its relationship with cost by the hospital's billing department); hospitalization and hospital observation time.
After medical records were analyzed, patients were reclassified according to their final diagnosis as either primary headache or secondary headache, following the criteria provided by the International Classification of Headache Disorders (ICHD-3). 5 Afterward, the aforementioned variables were analyzed according to the primary headache and secondary headache diagnoses.
A comparison was drawn between the number of consultations selected for this study (headache patients) and the total number of consultations with patients above 18 years of age at the Barbacena City Regional Hospital in 2019.

Data Analysis
The data collected through the analysis of medical records were The existence of a relationship between variables was measured through chi-square tests and Fisher's exact test. The existence of a relationship between qualitative and quantitative variables was measured through Student's t-test, ANOVA, Mann-Whitney, or Kruskal-Wallis U tests, as indicated. The study considered as statistically significant differences those with p value was under 0.05  (Table 1).    External causes injuries (S00 -T98) 4 0,9

Results
No discharge summary 30 6,7 Total 450 100 ASAA Oliveira LB, Guimarães J, Silva DJ, Jurno ME Headache diagnosis in an urgency and emergency unit: Public Health Relevance and its relationship with cost Table 3 shows the final diagnoses organized according to disease group, following the ICD-10. 10 Diagnoses under the "nervous system diseases" group were differentiated according to the specific ICD. In the case of the "Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified", it became evident that the headache ICD (R51) was employed in isolation or in association to other codes.  Out of the 315 consultations in which the distinction between primary and secondary headaches was achievable, interconsultation with neurology services was requested in 23 primary headache cases and in 38 secondary headache cases. Chances of interconsultation with neurology were 2.46 times higher (95%CI 1.38 to 4.38) for secondary headache than in primary headaches (X² p=0.002). Chances of head CT were 4.55 times higher for secondary headache cases (95%CI 2.44 to 8.52 -X² p<0.001). CSF analysis was conducted in only one primary headache case compared to 9 punctures requested for secondary headaches. Only one primary headache case resulted in hospitalization - Table 4.

Discussion
Headache is one of the most frequent conditions reported in medical practice. 1,11,12 It causes incapacitation and loss of life, motivating a great part of patients suffering from this symptom to search for urgency and emergency care. According to some studies, headaches respond to 0.5% to 2.8% of consultations in emergency care units. 13,14 Our study endorses these statistics, showing that headache complaints corresponded to 1.8% of consultations in the emergency care department of the Barbacena City's Regional Hospital in 2019.
Headaches etiological diagnosis was proven to be a challenge, as described in previous accounts. 2,4,15 30% of patients were discharged with no definitive diagnosis of the cause for their symptoms, as observed in another study. 16 The final IDC-10 attributed to 49.8% of the cases was solely Headache (R51). In other words, almost half of the patients left the hospital having received no explanation for their symptoms. It is known that efficient headache treatment is directly connected to the diagnosis according to the ICHD-3 criteria 5,15 , which cannot be determined for an expressive portion of patients evaluated in our study.
Among the available methods for determining headache causes, interconsultations with specialists were 2.46 times more used in secondary headache cases than in primary headache cases. Head CTs were performed 4.55 more times for secondary headaches; CSF analysis and necessity of hospitalization also occurred in a higher proportion than secondary headaches when compared to primary headaches. On the other hand, the strength of this study is allowing the demonstration of the expressive financial impact patients with headache complaints entail to the hospital, even taking into consideration that the displayed values correspond only to a portion of actual expenditures. Therefore, this study emphasizes the importance of accurate diagnosis and rational use of available resources for better management of these patients.

Conclusion
The socio-economic impact caused by headaches is unquestionable. It is a highly frequent symptom and both its etiological distinction and adequate treatment require solid evaluation. Due to the resources spent in its evaluation and monitoring, headaches can be considered a public health problem. Therefore, this study suggests that resources should be allocated in the health education and professional training for the proper conduction of these patients, so that they may benefit from an optimized treatment of their condition without overwhelming the health system.

Ethic Approval and Patient Consent
All procedures in this study were in accordance with the ethical standards of the responsible committee on human experimentation from Hospital Foundation of the State of Minas Gerais -FHEMIG with approval number 4.127.307. Informed consent was obtained from all patients for being included in the study.