Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Unspecified headache is a common discharge diagnosis in the pediatric emergency department (ED). While diagnostic uncertainty and limited access to specialty evaluation may contribute to repeat ED visits in this population, longitudinal utilization data are limited. Study objectives were both to determine the incidence of repeat headache-related ED visits in children discharged from the ED with unspecified headache and to identify predictors of ED return (eg, prior headache-related ED or neurology utilization).

Methods: This preliminary, prospective longitudinal cohort study included 76 children (ages 8–17 years) discharged from the ED with an unspecified headache diagnosis. We assessed headache-related ED and outpatient neurology visits both six months after the index visit (ie, ED enrollment) and, retrospectively, 12 months before the index visit. The sample included children insured through a Medi-Cal–based Physician-Hospital Consortium, who receive care exclusively within an integrated healthcare network, and other children in the hospital network, allowing capture of all ED and clinic utilization data. Our primary outcome was incidence of headache-related ED utilization postindex visit. Pain characteristics were self-reported during the index visit. Chi-square, Mann-Whitney U, and logistic regression analyses examined factors associated with incidence of headache-related ED returns.

Results: Nearly 12% (n = 9) of children returned to the ED for a headache 6 months following the index visit. Across the 18-month study, 22.4% had at least one headache-related ED visit outside the index visit, 64.7% (n = 11) of whom had >2 headache-related ED encounters. A prior headache-related ED visit or prior neurology visit was significantly associated with returning to the ED after the index visit (20.0% vs 3.0%; risk difference = 17.0%; 95% CI, 0.9%-48.0%; P = .03, and 37.5% vs 1.5%; risk difference = 28.7%; 95% CI, 3.2%-60.9%; P = .02, respectively). Children with more than two headache-related ED visits during the 18-month study reported higher pain intensity (7.00 [SD, 1.38] vs 5.79 [SD, 2.09]; mean difference = -1.21; 95% CI, -2.20 to -0.22; P = .02). In logistic regression analyses, prior neurology utilization was the only variable significantly associated with headache-related ED return (OR, 15.31; 95% CI, 1.08-216.34; P = .04).

Conclusion: A considerable proportion of children discharged with unspecified headache returned to the ED for headache. Emergency department and neurology utilization and pain intensity were linked to return ED visits. Larger, longitudinal studies are needed to further clarify these findings.