Introduction: Benign headache (BHA) management varies across emergency departments (EDs). This study documented current BHA management by Alberta emergency physicians (EP) in order to develop a provincial intervention to improve standardized practice. Methods: A convenience sample of Alberta EPs completed an online survey exploring their ED BHA management practices. Results are expressed as proportions. Results: A total of 73 EPs (73/192; 38%) who were mostly male (63%) and practiced emergency medicine for at least 15 years (51%) responded. EPs reported routine ED orders for metoclopramide (97%), ketorolac (90%) and IV fluids (85%) for patients with BHA showing no signs of pathological headache. For moderate-severe BHA's that did not improve with routine treatment, preferences were: IV narcotic (58%), IV dexamethasone (44%), and IV/IM dihydroergotamine (27%). Typically, EPs reported not ordering investigations for moderate-severe BHA presentations (88%); however, for those not improving the most common investigation was computed tomography (CT; 47%). CT ordering was associated with the following clinical scenarios: 1) not responding to traditional therapy and consulted to specialist (64%); 2) not responding to traditional therapy and being admitted (64%); 3) first presentation and afebrile (19%); 4) severe pain (11%); and 5) responding to traditional therapy and febrile (11%). One-quarter of EPs (27%) believed their patients usually or frequently expected a CT. Most EPs (60%) reported being completely or mostly comfortable discussing CT risks. Only 44% reported always or usually discussing risks prior to ordering. EPs reported that they were most frequently prevented from discussing risks because the patient was critically ill (42%) or because they believed explaining risks would not alter patient expectations (21%). These concerns were mirrored in the barriers EPs anticipated to limiting imaging, specifically the fear of missing a severe condition (62%), and patient expectation/request for imaging (48%). Conclusion: Self-reported treatment preferences for uncomplicated BHAs appear to be relatively consistent. Chart reviews could help assessing the reliability of self-reported BHA management practices. Perceived patient expectation appears to be an important influence on EP imaging ordering. Studies examining the communication between EPs and their patients are needed to explore how these expectations and perceived expectations are negotiated in the ED.

Introduction: Variation in medication management and image ordering for HA presentation to emergency departments (ED) has been documented. This study examined benign HA (i.e., migraine, cluster, tension) management in order to identify the consistency and appropriateness of HA management in EDs in Alberta. Methods: Patients were identified by primary discharge diagnosis in the National Ambulatory Care Reporting System using ICD-10-CA codes for benign HA (G43, G44, R51). Patients presenting to study sites from January 1, 2017 to September 30, 2017 were eligible for inclusion, provided they were adults (≥18 years), were not transferred from another institution or directly admitted to a service, and had an active HA at presentation. One hundred eligible patients were randomly selected for chart review. Data were extracted on standardized forms. Preliminary data on 50 patients (n = 150) from three Edmonton study sites is presented. Results: Most patients arrived to the ED via personal transportation (93%) and were assigned a Canadian Triage and Acuity Scale (CTAS) score of 3 (71%). The majority of patients were female (75%); mean age was 45 years (standard deviation: 18). Triage pain score was not documented for 21%. When documented, pain scores were most frequently between 4 and 7 (49%). Nearly 10% of patients left without being seen. For those who were assessed, physicians most frequently used ketorolac and metoclopramide as first or second line treatments or as a combination treatment. Consults were infrequent (14%). Nearly half of the patients (47%). had computed tomography (CT) in the ED. Pain re-assessment was completed for 69% of patients. Most patients were discharged from the ED (88%) and given some form of discharge instruction (78%). The most common instructions were to return to ED as needed (45%) and follow-up with their primary care physician (28%). Across all patients, 13% returned to the ED with headache within 30 days. Conclusion: Physicians treat patients with benign headaches appropriately and hospitalization is infrequent; however, one in eight patients relapse. Missing pain scale documentation reveals a potential problem for ED clinicians in assessing management effectiveness and ensuring patients leave the ED following pain relief. Half of the patients received a CT scan, highlighting the urgent need for an intervention to address CT overuse for patients with benign HA within this geographic region.