To identify factors associated with hospitalization for cerebrovascular disease (CVD) after an Emergency Department (ED) discharge with a diagnosis of primary headache.

When patients discharged from the ED with a primary headache diagnosis return with CVD this may represent a preventable medical error.  

We conducted a retrospective nested case-control study using a cohort of headache patients seen in 1 of 4 EDs from 9/1/2013 to 9/1/2018.  Eligible patients were discharged home with a diagnosis of primary headache. Within 365 days of ED discharge, cases had a subsequent hospitalization for CVD, while controls did not. Controls were matched to cases based on date of ED arrival and ED facility. Covariates were abstracted by chart review and all CVD outcomes were confirmed by a board-certified vascular neurologist. We used standard tests of comparison to compare cases to controls setting an alpha <0.05.

A total of 224 patients were included in our study; 112 cases and 112 controls. In both groups, 67% (n=75) of patients were female and most were English speaking (71.4% vs. 75%, p=0.65). On average, cases were older than controls (63.5 SD: 15.9 vs. 41.7 SD: 14.8, p=0.001) and were more likely to be Black or African American (39.3% vs. 25.9%, p=0.05). Additional variables including presenting symptoms, vascular comorbidities, headache features, and medications are being assessed.  

Patients discharged from the ED with a primary headache diagnosis and subsequently hospitalized for CVD are older and more often Black or African American than those without subsequent CVD hospitalization. Factors associated with misdiagnosis (minority race) and CVD risk (advanced age) are associated with subsequent CVD hospitalization; addition data collection is ongoing to improve risk stratification. Awareness of these factors may improve the detection of CVD in patients presenting with headache.