Headache Medicine 2021, 12(1) p-ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2021.8

Headache Medicine

Original

Headache diagnosis in an urgency and emergency unit: Public Health

Relevance and its relationship with cost

Lígia Barros de Oliveira

Jessica Guimarães

Danilo Jorge da Silva

Mauro Eduardo Jurno

1,3

Hospital Foundation of the State of Minas Gerais – FHEMIG, Barbacena, Brazil

University Hospital, Federal University of Juiz de Fora, Brazil

Barbacena School of Medicine, Barbacena, Brazil

Abstract

Background

Headache is a common symptom that affects a signicant 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

insufciency 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 Rele-

vance 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 nal 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 classied. The resources utilized for secondary headaches diagnosis differed

signicantly from those used in primary headache diagnosis. However, the nal 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 benet from an optimized treatment of their

condition without overwhelming the health system.

Lígia Barros de Oliveira, R João

Pinheiro, 923, ap 502, 36201-

128, Barbacena-MG, Brazil.

ligiabarrosdeoliveira@yahoo.

com.br

Edited by:

Marcelo Moraes Valença

Keywords:

Migraine

Diagnosis

Headache

Health Expenditures

Emergency Medical Services

Public Health

Received: July 7, 2021

Accepted: August 22, 2021

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

Introduction

eadache is a universally occurring symptom that affects a

signicant portion of the general population. In Brazil, the

estimated annual headache prevalence is 61.6% among men

and 77.8% among women.

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 diagno-

ses, which range from benign conditions to high morbimortality

causes, and the time and resources available for proper patient

assessment.

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 nal diagnosis given by a neurologist.

Among these neurological conditions, primary headaches present-

ed one of the highest dissent rates.

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.

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 efcacious treatment for the pain.

In order to do

so, it is recommended to differentiate primary headaches (recurrent

headache crises are the main symptom) from secondary head-

aches (the headache is a symptom of an underlying systemic or

neurological disease).

The etiological denition 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.

The

evaluated indirect costs related to migraine-related absenteeism

and presenteeism equaled US$18.6 billion per year.

The Italian National Health System’s (NHS) average annual cost re-

lated 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.

This paper aimed at evaluating the diagnosis, the utilized resourc-

es, 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 Classi-

cation of Diseases (ICD-10).

R51: Headache

G43: Migraine

G43.0: Migraine without aura (common migraine)

G43.1: Migraine with aura (classic migraine)

G43.3: Complicated Migraine

G43.8: Other migraine

G43.9: Migraine, unspecied

G44: Other headache syndromes

G44.0: Cluster headaches

G44.1: Vascular headache, not elsewhere classied

G44.2: Tension-type headache

G44.3: Chronic post-traumatic headache

G44.4: Drug-induced headache, not elsewhere classied

G44.8: Other specied headache syndromes

The study’s exclusion criteria were: patients under 18 years of

age and consultations in which headache was not part of the

patient's initial complaints.

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

nal diagnosis; total cost of consultation, discriminating imaging

test costs and medication costs (based on documentation provided

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

by the hospital’s billing department); hospitalization and hospital

observation time.

After medical records were analyzed, patients were reclassied

according to their nal diagnosis as either primary headache

or secondary headache, following the criteria provided by the

International Classication of Headache Disorders (ICHD-3).

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

transcribed into an electronic spreadsheet and processed in the

statistical software SPSS Statistics 22.0.

Relative and absolute distributions were calculated for qualitative

variables. Continuous variables were veried under the Kolmog-

orov-Smirnov method normality percepts and listed as the measure

for central tendency and mean deviation, and standard deviation

for parametric or median distribution, and interquartile distance

for non-parametric distributions.

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

-test, ANOVA, Mann-Whitney, or

Kruskal-Wallis U tests, as indicated. The study considered as sta-

tistically signicant differences those with

value was under 0.05

Results

A total of 460 patient medical records were analyzed, which

corresponded to 501 consultations due to headache complaints

in 2019. Sixteen consultations in which headache was not part of

the initial complaints were excluded. 35 consultations for under 18

years of age patients were also removed. Thus, 450 consultations

were included in the analysis (Figure 1).

The total number of consultations at Barbacena City Regional Hos-

pital emergency care in 2019 for above 18 years of age patients

equaled 24,809. Thus 1.8% of hospital visits were motivated by

headache complaints.

The total number of consultations at Barbacena City Regional Hos-

pital emergency care in 2019 for above 18 years of age patients

equaled 24,809. Thus 1.8% of hospital visits were motivated by

headache complaints

Figure 1. Selection of patients for the study.

Three hundred and twenty-one of the headache-motivated consul-

tations corresponded to female patients (71%) and 129 to male

patients. Interconsultation with neurology services was necessary

in 65 cases (14.4%) and 69 patients (15.3%) underwent head

CT. Lumbar puncture realization for CSF analysis was needed

in 11 (2.4%) of events and a total of 12 (2.6%) patients needed

hospitalization (Table 1).

Table 1. Distribution of assistance according to variables of interest.

n %

Age (years) 41 ± 15

Gender

F 322 71,6

M 128 28,4

Interconsultation

with Neurologist

No 385 85,6

Yes 65 14,4

Head CT

No 381 84,7

Yes 69 15,3

CSF analysis

No 439 97, 6

Yes 11 2,4

Hospitalization

No 438 97,3

12 2,7

CT: Computed Tomography; CSF: Cerebrospinal Fluid.

With respect to hospitalization time, 406 cases needed up to one

day of observation (90.2%) and the percentage of accumulated

cases that demanded up to two days of hospitalization repre-

sented 95.3% of the sample. Sporadic cases demanded over ve

days of hospitalization.

Total expenditure (TE) was dened as the sum of imaging exams

costs, medication costs, daily hospital stay costs, according to

the following:

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

TE: Imaging costs + Medication costs + (daily stay price + obser-

vation time).

According to documents obtained in the hospital’s billing sector,

daily stays in the emergency care were not charged. This caused

these patients' expenditures to be much lower when compared to

the rest of the consultations. To standardize costs calculation and

minimize systematic errors in this variable with minimal loss, the

formula mentioned above was deployed.

This resulted in estimated total expenditures with the headache

patients care in 2019 equaling US$ 90,855.60, with a median

of US$129.73 and an average of US$201.90 per patient. Out of

the total value, US$1,827.09 (2.0%) were spent on imaging tests

and US$4,735.21 (5.2%) were spent on medication.

Among all 450 consultations, 25% presented imaging-related

expenses, and 15.3% of the cases involved the performing of at

least one head CT. In these cases, the imaging-related expenses

median was US$4.39.

Regarding the expenditures with medication, expenses reached

the maximum values the equaled up to US$1,667.76 per hospi-

talization. Only 1.49% of consultations did not compute onus.

Values of up to US$2.57 represented an accumulated percentage

of 90.0% of the consultations under study. Among the cases in

which medication expenses were incurred, these presented a

median of US$0.52.

Most initial diagnoses were syndromic, and Headache (R51)

corresponded to 299 (66.4%) of consultations. Cases of Migraine

(G34), Migraine without Aura (G430), Migraine with Aura (G431),

and Other Migraine (G438) totalized 97 (21.6%) of consultations

and cases initially attributed to tension-type headache were the

third most common motivation for seeking treatment - Table 2.

Table 2. Initial Diagnostics.

Initial Diagnostics n %

R51 - Headache 299 66,4

Clustered cases of Migraine

G43 - Migraine 52 11,6

G430 - Migraine without aura [common migraine] 20 4,4

G431 - Migraine with aura [classic migraine] 17 3,8

G438 - Other forms of migraine 2 0,4

G439 - Migraine, unspecied 6 1,3

G44 - Other cephalic pain syndromes 5 1,1

G441 - Vascular headache, not elsewhere classied 3 0,7

G442 - Tension-type headache 38 8,4

G443 - Chronic post-traumatic headache 1 0,2

G444 - Drug-induced headache, not elsewhere classied 2 0,4

G448 - Other specied headache syndromes 5 1,1

Total 450 100,0

Thus, initial consultation, the number of cases with sufcient

elements for classifying the headache as primary, according

to the criteria established by the International ICHD-3

corresponded to 135 (30%). As for the classication of the

headache as secondary, this number equaled 6 cases (1.3%).

The remaining 309 cases (68.7%) did not satisfy the criteria

classication.

Regarding the nal diagnoses registered in medical records, 224

cases (49.8%) maintained the syndromic description of headache

with no additional elements for etiological classication.

Migraine variants were the principal etiological diagnostic in

emergency care visits, accounting for a total of 102 (22.6%)

registered events. Tension-type headache was the second most

prevalent etiology present in the discharge summaries, totalizing

26 cases (5.7%). In 30 consultations, there was no register in

the discharge summary clinical evolution in the patient’s nal

evaluation.

Table 3. Final Diagnostics.

Final Diagnostic n %

Infectious and parasitic diseases (A00 - B99) 2 0,4

Neoplasms (C00 - D48) 1 0,2

Mental and behavioral disorders (F00 - F99) 5 1,1

Nervous System Diseases (G00 - G99)

G00 – Bacterial meningitis 1 0,2

G009 – Unspecied bacterial meningitis 1 0,2

G039 – Unspecied meningitis 1 0,2

G43 – Migraine 52 11,6

G430 – Migraine without aura [common migraine] 24 5,3

G431 – Migraine with aura [classic migraine] 17 3,8

G438 – Other forms of migraine 2 0,4

G439 – Migraine, unspecied 5 1,1

G44 – Other cephalic pain syndromes 4 0 ,9

G441 – Vascular headache, not elsewhere classied 2 0,4

G442 – Tension-type headache 26 5,8

G444 – Drug-induced headache, not elsewhere

classied

1 0,2

G448 – Other specied headache syndromes 2 0,4

G510 – Bell's Palsy 2 0,4

Circulatory System Diseases (I00 - I99) 8 1,8

Respiratory System Diseases (J00 - J99) 4 0 ,9

Musculoskeletal System Diseases (M00 - M99) 5 1,1

Genitourinary System Diseases (N00 - N99) 2 0,4

Abnormal symptoms and signs from clinical and laboratory

examinations, not elsewhere classied (R00 - R99)

6 1,2

R51 – Headache 224 49,8

R51 – Headache + another ICD 19 4,2

External causes injuries (S00 - T98) 4 0 ,9

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 nal diagnoses organized according to disease

group, following the ICD-10.

Diagnoses under the “nervous sys-

tem diseases” group were differentiated according to the specic

ICD. In the case of the “Symptoms, signs and abnormal clinical

and laboratory ndings, not elsewhere classied”, it became

evident that the headache ICD (R51) was employed in isolation

or in association to other codes.

After the individual medical records analysis, a reclassication of

primary and secondary headaches was performed following the

criteria established by ICHD-3.

Primary headache preserved a

similar proportion in nal diagnoses in relation to initial diagnoses

(38.9% and 30% respectively). Secondary headaches presented

a signicant increase in the nal evaluations (31.1% versus 1.3 %

in initial evaluations). For a signicant portion of patients, data

described in the medical records were still insufcient for such

classication (135 cases, which corresponds to 30% of consulta-

tions), although in a lower proportion in comparison to the initial

consultation (68.7%) - Figure 2.

Figure 2. Comparison of initial and nal diagnoses after analysis of medical records

regarding primary and secondary headaches.

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.

Table 4. Proportion of cases of primary and secondary headache according to variables

of interest.

Secondary

Headache

Primary

Headache

Odds

Ratio

p *

Interconsultation

with Neurologist

Yes 38 23

2,46 0,002

No 102 152

Head CT

Yes 44 16

4,55 <0,001

No 96 159

CSF analysis

Yes 9 1

0,006

No 131 174

Hospitalization

Yes 11 1

0,002

No 129 174

N = 315. a Secondary / Primary. * Chi- square (x²) unless otherwise indicated. b

Fischer's exact.

CT: Computed Tomography; CSF: Cerebrospinal Fluid.

The median age was higher for the secondary headache group

(41 years of age, compared to 38 for primary), presenting a

signicantly distinct distribution (p = 0.019, Mann-Whitney test).

Similarly, higher costs related to imaging were attributed to

secondary headache, with values reaching up to US$336.92

(average US$10.35± 3.19), in comparison to a maximum cost of

US$18.54 (average US$1.01±0.24) for primary headaches, with

signicantly different cost distribution curves (p<0.001, Mann-

Whitney test). However, there were no signicant differences in

medication costs, hospital stay, or total costs for the two headache

groups (Mann-Whitney test, 0.951, p = 0.229 and 0.275

respectively) – Table 5.

Table 5. Age and costs according to secondary and primary headache.

Variable

Primary

Heada-

che

Secun-

dary

Heada-

che

Hospitali-

zation

Non-

-hospi-

taliza-

tion

Age

(years)

Median 38 41

0,019

57 40

0,043Minimum 18 18 18 18

Maximum 85 89 89 92

Costs

related to

imaging

test

(US $)

Median 0,00 0,00

<0,001

23,80 0,00

<0,001

Minimum 0,00 0,00 0,00 0,00

Maximum 18,54 336,92 336,92 126,25

Medication

costs

(US $)

Median 0,56 0,50

0,951

74,04 0,51

<0,001Minimum 0,00 0,00 2,57 0,00

Maximum 155,32 1.667,76 1.667,76 155,54

Hospital

stay costs

(US $)

Median 135,00 129,48

0,229

1.362,58 123,95

<0,001Minimum 88,51 88,51 311,47 88,51

Maximum 1.639,75 5.949,70 5.949,70 712,47

Total costs

(US $)

Median 136,14 135,24

0,275

1.438,57 127,26

<0,001Minimum 88,99 88,51 332,58 88,51

Maximum 1.644,23 6.606,18 6.606,18 736,63

a Mann Whitney U Test, n = 315. b Mann Whitney U Test, n = 450.

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

Total costs were higher among the group of patients who needed

hospitalization regardless of headache classication, with a median

of US$1,483.57. For patients who did not require hospitalization,

the median of total costs equaled US$127.26, with a signicantly

different distribution in comparison to those in in-patient care

(p<0.001, Mann-Whitney test). The median age equaled 57

years of age for in-patients (IQR 37) compared to 40 years of

age for patients who were not hospitalized (IQR 23), presenting a

signicantly different distribution – Table 5.

Total costs did not vary signicantly according to sex (p=0.495,

Mann-Whitney test). The same was observed for age and the other

cost categories (p>0.05, Mann-Whitney test).

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 denitive diagnosis of the cause for their

symptoms, as observed in another study.

The nal 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

efcient 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. The study identied signicant differences for

all parameters. Thus, imaging test costs were more prominent for

the secondary headache group (Average US$10.35±3.19) than for

the primary headache group (Average US$1.01±0.24). However,

no signicant differences in medication costs, hospital stay costs,

and total cost of consultation among the two headache groups.

The estimated expenditures with headache patients in Barbacena

City Regional Hospital equated US$90,855.60 (average

US$201.90 per patient) in 2019. This conrms the great nancial

impact generated by this condition.

7,9,12

Part of headache patient-related expenditures included the

performance of imagining tests. In this study, head CT costs

corresponded to 2% of the total value. Nonetheless, it has been

demonstrated that out of all head CTs performed in headache or

facial patients at urgency departments, 95% may be normal.

4,14

Therefore, identifying which cases actually require imaging tests

can be an important factor in expenditure control.

As a transversal retrospective cohort study based on medical

records analysis, this study presented some limitations. Since

patient follow-up after discharge is not available, the diagnostic

conrmation for suspected conditions reported in the medical

records could not be conrmed. Diagnoses were determined

based on the emergency care records, which may not have been

precise. Oftentimes, specic and important features of a patient's

history and physical exams were not available and, thus, the

etiology attributed to headache could not be accurately analyzed.

Additionally, the denition of hospital expenditures was based on

the Brazilian National Health System’s table, with standardized

values in which costs related to procedures performed during

hospital care are based.

However, these values represent only a portion of what is

actually spent in practice, since costs related to physical structure

maintenance, CT equipment maintenance, human resources

necessary for patient care, supplies used in laboratory exams,

among other costs, were not included in the estimations. Thus,

we can draw only limited conclusions about the rational use of

available resources for the diagnosis of headaches and the actual

expenditures related to patient care.

On the other hand, the strength of this study is allowing the

demonstration of the expressive nancial 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

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

patients, so that they may benet 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.

Conict of interest: None

Financing: None

Lígia Barros de Oliveira: Conceptualization, Data curation,

Investigation, Project administration, Resources, Visualization,

Writing – original draft.

Jessica Guimarães: Data curation, Investigation, Resources,

Writing – original draft.

Danilo Jorge da Silva: Data curation, Formal analysis, Software,

Writing – original draft.

Mauro Eduardo Jurno: Conceptualization, Investigation,

Methodology, Project administration, Resources, Supervision,

Visualization, Writing – review & editing

Lígia Barros de Oliveira

https://orcid.org/ 0000-0002-6715-6590

Jessica Guimarães

https://orcid.org/ 0000-0003-0640-0470

Danilo Jorge da Silva

https://orcid.org/ 0000-0002-8086-1200

Mauro Eduardo Jurno

https://orcid.org/ 0000-0002-8743-9395

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