Diagnostic and therapeutic errors in cluster headache: a hospital-based study.

BACKGROUND: Cluster headache (CH) is a severe, disabling form of headache. Even though CH has a typical clinical picture it seems that its diagnosis is often missed or delayed in clinical practice. CH patients may thus face: misdiagnosis, unnecessary investigations and delays in accessing adequate treatment. This study was conducted to investigate the occurrence of diagnostic and therapeutic errors with a view to improving the clinical and instrumental work-up in affected patients. METHODS: Our study comprised 144 episodic CH patients: 116 from Italy and 28 from Eastern European countries (Moldova, Ukraine, Bulgaria). One hundred six patients (73.6%) were examined personally and 38 (26.4%) were evaluated through telephone interviews conducted by headache specialists using an ad hoc questionnaire developed by the authors. RESULTS: The sample was predominantly male (M:F ratio 2.79:1) and had a mean age of 42.4 ± 9.8 years; approximately 76% of the patients had already consulted a physician about their CH at the onset of the disease. The mean interval between onset of the disease and first consultation at a headache center was 4.1 ± 5.6 years. The patients had consulted different specialists prior to receiving their CH diagnosis: neurologists (49%), primary care physicians (35%), ENT specialists (10%), dentists (3%), etc. Misdiagnoses at first consultation were recorded in 77% of the cases: trigeminal neuralgia (22%), migraine without aura (19%), sinusitis (15%), etc. The average "diagnostic delay" was 5.3 ± 6.4 years and the condition was diagnosed approximately ("doctor delay": one year). Instrumental and laboratory investigations were carried out in 93% of the patients prior to diagnosis of CH. Some of the patients had never received abortive or preventive medications, either before or after diagnosis. Medical prescription compliance: 88% of the cases. CONCLUSIONS: Our results emphasize the need to improve specialist education in this field in order to improve recognition of the clinical picture of CH and increase knowledge of the proper medical treatments for de novo CH. Continuous medical education on CH should target general neurologists, primary care physicians, ENT specialists and dentists. A study on a larger population of CH patients may further improve error-avoidance strategies.

Diagnostic and therapeutic errors in trigeminal autonomic cephalalgias and hemicrania continua: a systematic review.

Trigeminal autonomic cephalalgias (TACs) and hemicrania continua (HC) are relatively rare but clinically rather well-defined primary headaches. Despite the existence of clear-cut diagnostic criteria (The International Classification of Headache Disorders, 2nd edition - ICHD-II) and several therapeutic guidelines, errors in workup and treatment of these conditions are frequent in clinical practice. We set out to review all available published data on mismanagement of TACs and HC patients in order to understand and avoid its causes. The search strategy identified 22 published studies. The most frequent errors described in the management of patients with TACs and HC are: referral to wrong type of specialist, diagnostic delay, misdiagnosis, and the use of treatments without overt indication. Migraine with and without aura, trigeminal neuralgia, sinus infection, dental pain and temporomandibular dysfunction are the disorders most frequently overdiagnosed. Even when the clinical picture is clear-cut, TACs and HC are frequently not recognized and/or mistaken for other disorders, not only by general physicians, dentists and ENT surgeons, but also by neurologists and headache specialists. This seems to be due to limited knowledge of the specific characteristics and variants of these disorders, and it results in the unnecessary prescription of ineffective and sometimes invasive treatments which may have negative consequences for patients. Greater knowledge of and education about these disorders, among both primary care physicians and headache specialists, might contribute to improving the quality of life of TACs and HC patients.

Diagnostic delay and suboptimal management in a referral population with hemicrania continua.

AIM OF THE STUDY: To investigate a clinical population of patients with hemicrania continua (HC), looking at the diagnostic problems they have encountered and their use of healthcare resources and at issues relating to the effectiveness of treatments. MATERIALS AND METHODS: We directly interviewed 25 patients fulfilling the International Classification of Headache Disorders, 2nd edition diagnostic criteria for HC selected among 1612 subjects attending the INI Grottaferrata Headache Clinic over a 3-year period. RESULTS: No patient had received a correct diagnosis before being seen at our headache clinic. In total, 85% of the patients consulted a physician within 5 months of the onset of the symptoms but mean time to diagnosis was 5 years (SD 4.9). The average number of physicians seen before the condition was properly diagnosed was 4.6 (SD 2.2). General practitioners (100%), neurologists (80%), ear, nose, and throat surgeons (44%), ophthalmologists (40%), and dentists (32%) were the physicians most commonly consulted. All the patients had previously received an incorrect diagnosis. Migraine (52%), CH (28%), sinus headache (20%), and dental pain (20%) were the most common wrong diagnoses reported. Some 36.0% of patients had undergone ineffective invasive treatments. The patients had tried, on average, 3.6 (SD 2.1) classes of drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs) (92%), triptans (32%), antidepressants (32%), and antiepileptics (24%) were the most commonly used. Patients rated 73.7% of medications as ineffective, 22.5% (all NSAIDs) as partially effective, and 3.7% (rofecoxib and nimesulide) as effective. CONCLUSIONS: Hemicrania continua may be misdiagnosed and mistreated even by neurologists. There is a need for greater awareness and understanding of this condition.