Headaches

[Pinner Doc]

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It has been suggested to me that I'm rather conservative in my approach to patients, with headaches as an example.

My approach is to suss out whether the patient has a history of headaches, whether this headache is similar to those (and if it's different, how), if the headache was sudden in onset, or if it's the worst of his life. (I also take into account comorbidities, such as HIV, etc). If the headache is WOL, or different from other headaches, or thunder-clap (or associated with fever/nuchal rigidity/etc), I tend to CT and LP.

The problem is, I seem to have a disproportionate number of patients who tell me, "Oh, yes, doctor. This is the WORST headache of my life." Or, "This is headache is *completely* different than my other headaches." Because I hear this so often, on occasion I even do tell my patients my concerns - such as, "I'm asking these questions because it's important for me to discern if this is a life-threatening cause of headache, such as something that would necessitate a spinal tap," or something along those lines. That way, I figure the over-exaggerators are less prone to do so.

Still, I keep hearing those buzz words from my patients and, in effect, feel obligated to do the CT/LP workup seemingly quite often. Thus the feedback from my staff that I seem to "CT everyone with headache." I'd like to think this is not the case. Does anyone else have a better approach to headache?

 

[USCDiver]

I ask, "When was the last time you had a headache this bad?" That answers several of the above questions without leading them into the 'worst headache' phrasing.

 

[Interpolfanclub]

One of the giant pitfalls of EM is being led astray by ancillary staff "he's always here for this doc, he always has a headache etc" or by the patients themselves. I think your approach to HA is appropriate. Don't make things too complicated. One of my partners breaks it down like this: worst HA ever? getting tapped. Hx of HA but this one is different? getting tapped. Her explanation was that she didn't want to over analyze it and with that algorithm she doesn't.

Err on the side of the LP or advise the patient they need an LP and let them refuse and document that. I wouldn't change your practice based on staff chatter.

 

[deleted65604]

I think my practice style is probably similar Pinner's and Interpol's.

I have a conversation explaining the risks and benefits of procedures versus missing serious diagnoses, talking specifically about meningitis, SAH, and post-LP headaches. Then, you recommend that the patient get the procedure done if there are any red flags. If I have a low suspicion, and really don't think an LP is necessary, I might say, "If I were a betting man, I'd say that this isn't something dangerous, but to rule out all emergencies beyond a shadow of a doubt, we should do an LP." If it is a semi-intelligent conversation, I leave the decision up to the patient. That way, I can document a well informed refusal. Those patients are happy about being well informed, avoiding potentially invasive procedures and tests, and will ideally return for any change in status. Heck, a half intelligent person will come back and specifically say..."The other doc wanted to do an LP, I refused, now I want it."

If I get the deer in the head-light look that tells me that they are too stupid to make a well-informed decision, I just tell the patient I'm going to do an LP, and short of them getting off the table and running out of the room, I don't leave the decision to them.

I'm also more careful in those patient who are the swooning, overly dramatic patients that don't like to talk much about risks and benefits. When a patient gives me the, "Well YOU'RE the doctor!" line, I'm more conservative. Instead of saying what I want to say...("Well YOU"RE the patient, and I can't put myself in your body and feel what you are feeling *****,") they get a needle in the back.

It's tough when your patient can't understand a simple conversation about risks and benefits, or aren't interested in being a well informed patient. I don't trust the historical information given to me by these patients enough to not revert to vet-medicine mode. I fear those patients that seem to expect me to wave a wand, diagnose and treat their problem with no input on their part. It seems to me, that they would be the most likely patient to sue a doctor or complain about adverse outcomes, as they are expecting a super-human performance from me.

 

[xaelia]

I lean towards basing my CT/LP on the onset character of the headache (i.e., sudden, maximal at onset) rather than simply "worst ever". There's so much literature out there that taps so many "worst ever" headaches with <10% yield that I can't go crazy with only that.

Unfortunately, while there are clinical characteristics in various studies (most recently: http://www.bmj.com/content/341/bmj.c5204.long), the positive or negative likelihood ratios are not always going to be terribly helpful in making your decision.

 

[la gringa]

i agree w/ xaelia... i rely more on onset, context, if similar to their migraine if they have a hx. if it's gradual onset i press hard whether it's really the worst HA or if they just want whatever nonsense cocktail that includes narcotics they're looking for.

i see some other docs tap a ton of 20something women who had crappy stories to start, and then they're back for their post-LP headache. those same people also will be refractory to a blood patch, etc etc. talk about a HA!!!

and fwiw, i use narcs as an absolute last resort. i wish more of my colleagues did the same. narcs don't treat migraines well at all. i usually start w/ steroids/toradol (if not getting a CT)/phenergan (b/c it's in the pyxis - i really prefer compazine, and just use other nausea meds to buy time for the compazine to come from pharmacy just in case). and a pep talk. i give a meeean pep talk about things i feel strongly about (including: no narcs for migraines, no abx for viruses, try to send old people home if there's no clear benefit to admission, nice but stern intervention for domestic violence, don't hurt or threaten my coworkers)

 

[deleted109597]

Really, LP's aren't that hard, and if you fail after a few tries, admit them for someone else. If they refuse, then you're off the hook (for the most part). Remember, you're much more likely to be sued for not doing something than for doing too much in the ED. In surgery, this is different, as cutting off the wrong leg can happen. I've yet to LP the wrong patient.

But at the same time, I don't ask them if it's the worst headache of their life, because the patient often wrongly assumes that this means they're going to get more meds, and not more procedures.