Medical Legal Lessons: Headaches

Welcome back to our weekly Urgent Care RAP Friday lesson. As always, these are small snippets from HippoEd's Urgent Care Rap podcast. If I have provided enough value/you want to buy, use my link for $25 off. I get a small amount of money if you use my link & helps me continue to do what I love--urgent care medical education & sharing with you all. Link: here
 
This a summary of HippoEd’s UC rap May 2020 podcast chapter titled: “Legal lessons: Migraine vs stroke.” 

Headaches are probably one of the most common CC's in urgent care. It is also one of the chief complaints that I commonly write a lengthy medical decision note—specifically noting presence   or absence of alarm features, summary of my neuro exam, if I have recommended an ER visit, and /or if I have discussed symptom & time-specific follow-up

The case: 
The podcast chapter reviews a medical legal case of a woman with hx of migraines, presenting for CC of migraine headache, seeking migraine medication refill and stating she felt somewhat confused and disoriented. She had a second visit 3 days later—with worse HA and neurologic deficits. Pt note stated patient was disoriented and complained of vision changes. Pt was discharged home and accused of drug seeking. Patient had another bounce back 3 days later and was found to have a large embolic stroke. Patient sued both physicians

​Pearls: 

• Questions to ask: Have you ever had a HA like this in the past? Is there a history of chronic headaches? If so, is the headache the same as those prior? Are there any new symptoms? 
• ask about/note any neuro symptoms—unilateral numbness/weakness, facial droop, confusion
  • ​know that some migraine variants (hemiplegic migraine, complex migraines) may have abnormal neurologic findings (e.g. sensory/visual auras)
  • In reference to the case—this patient should have been asked if these neurologic symptoms are new. "When you have a migraine, do you typically have these neuro symptoms?"
• Alarm symptoms: Altered mental status and confusion are almost never features of benign headache syndromes, such a migraine
  • If you are in between two diagnoses, you should default to ruling out the most serious diagnosis. Your differential in this case was: migraine versus stroke
• Be leery of visits for medication refills as the patient may be presenting due to new/concerning symptoms
• In school, we’re taught to ask the patient "is this the worst headache of your life?" This may work in an OSCE setting, but rarely in real life. Asking “Is this the worst headache of your life?” poorly differentiates between serious and benign causes of headache
• History should focus on ensuring the headache was not sudden and maximal at onset and that there are no red flag neurologic symptoms or signs
• Documentation: your MDM should specify your thought process--why you think this is or is not a more ominous diagnosis. What have you ruled out? 
• Patient demographics & risk factors for non-benign HA etiologies: 
  • Older age
  • Immunocompromised—think about diabetic patients
  • Use of anticoagulation
  • Hypercoagulable state—cancer, oral contraceptive, pregnancy, history of factor V leiden

​Medical legal cases are always scary, but this was such an interesting case. You learn a lot from other people's mistakes & cases such as these, so hope this will help you in seeing those HA patients and you'll be able to catch these more ominous diagnoses!