Background. Headache is a common complaint among children in the emergency department (ED). Although usually benign in nature, some headaches are secondary to serious neurologic diagnoses (SND). We seek to characterize the proportion of patients discharged from the ED with a diagnosis of headache and found to have SNDs during subsequent visits. Methods. We performed a multicenter retrospective cohort study using data from forty-eight pediatric hospitals in the Pediatric Health Information System between October 1, 2015 and March 31, 2019. We included patients ≤18 years discharged from the ED with an ICD-10 primary diagnosis code for headache. We excluded patients with concurrent or prior known SNDs, neurosurgical history, and trauma. Our primary outcome was ED revisits with a diagnosis code for one or more SNDs within 30 days of the index ED visit for headache. We defined SNDs as one of 22 mutually exclusive categories of ICD-10 codes based on prior literature. We identified the rates, types and timing of SNDs. To determine if patients with SNDs had delayed diagnosis due to limited testing, as a secondary outcome, we compared the rates of diagnostic tests at the index visit between patients with and without SNDs. To evaluate whether our outcomes were confounded by a baseline incidence of SNDs independent of headache, we performed the same analysis on control groups with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. Results. There were 91,812 children with primary diagnosis codes of headache included in the study cohort (54% female, median age 11.6 years). There were 435 children (0.47%, 95% CI 0.43-0.51%) diagnosed with at least one SND within 30 days of their index visit. Most patients with SNDs were diagnosed within one follow up visit (80.9%), and 38.4% were diagnosed within one week (Figure). The most common SNDs were benign intracranial hypertension (21.9%), cerebral edema and compression (15.7%) and essential hypertension (11.9%) (Table). A greater proportion of patients with SNDs underwent neuroimaging, blood, and CSF studies at the index visit compared to patients without SNDs (p<0.001 for each test). The SND rate among patients diagnosed with headache was higher than in control cohorts (p<0.001 for each control). Conclusion. Fewer than 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SND within 30 days, with a low incidence of high-acuity disease. Notably, patients found to have SNDs on revisits underwent greater extent of diagnostic testing at the index visit than patients without SNDs, suggesting a higher degree of initial clinical suspicion. Further efforts to identify at-risk patients remain a clinical challenge and require further investigation.

Table

Serious neurologic diagnoses by frequency and follow-up period.

ICD-10, International Classification of Diseases, 10th edition. ADEM, acute disseminated encephalomyelitis. MELAS, mitochrondrial encephalopathy, lactic acidosis and stroke-like episodes.

Table

Serious neurologic diagnoses by frequency and follow-up period.

ICD-10, International Classification of Diseases, 10th edition. ADEM, acute disseminated encephalomyelitis. MELAS, mitochrondrial encephalopathy, lactic acidosis and stroke-like episodes.

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Figure

Patients diagnosed with SNDs over time.

Number of patients (left axis) and cumulative percent of patients (right axis) with SNDs diagnosed over time. SND, serious neurologic diagnosis.

Figure

Patients diagnosed with SNDs over time.

Number of patients (left axis) and cumulative percent of patients (right axis) with SNDs diagnosed over time. SND, serious neurologic diagnosis.

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