LO50: Headache presentations to emergency departments in Alberta: understanding investigative approaches

Introduction: Headaches are a common emergency department (ED) presentation. The objective of this study was to characterize headache presentations in Alberta over a five-year period and explore the proportion of patients with potentially severe pathology. Methods: Administrative health data for Alberta (years 2011-2015) were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) headache presentations (ICD-10-CA: G43, G44, R51). Patients with a primary or secondary diagnosis code of headache were eligible for inclusion in the study. Exclusions were made using the following criteria: 1) sites without computed tomography (CT) scanners; 2) presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1; 3) patients with trauma or external mechanism of injury (e.g., ICD-10-CA codes S,T,V,W,X,Y); and 4) presentations receiving an enhanced/contrast CT (head). NACRS data were linked with a provincial diagnostic imaging data. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, 98,333 presentations were made by 66,970 patients (~0.3 presentations per patient per year; equivalent to one presentation every 3.4 years). Headache presentations increased from 15,643 in 2011 to 21,636 in 2015. The median age was 38 years (IQR: 29, 51 years); more patients were female (69.3%), had a CTAS score of 3 (55%) and arrived at the ED without ambulance (90.3%). The majority of patients had a primary ED diagnosis of headache (88%) and the most common co-diagnosis was benign hypertension (2.8%). Additional diagnoses indicating severe or pathological headaches, included: stroke (0.63%), subarachnoid hemorrhage (0.43%), infection (i.e., meningitis) (0.11%), and other brain hemorrhages (0.08%). Overall, the ED management of approximately 25% of presentations involved a head CT. Most patients were discharged from the ED (89.4%) after a median length of stay of 3.5 hours (IQR: 2.1, 5.2 hours). Conclusion: Headache-related ED presentations are increasing in Alberta, yet few severe/pathological diagnoses are being identified. Efforts to ensure appropriateness of head CT ordering could reduce exposure to ionizing radiation, improve patient flow and reduce health care costs; this imaging represents a target for future interventions.