Headaches are among the most common source of visits to primary care PAs and are extremely elusive in their diagnosis. There are a total of over 300 types of headaches that we are aware of, and many of which have symptoms that are so intense that they rank among the ten most significant reasons for loss of wages and manpower in the workplace. Some headaches are a migraine variant which can present themselves in many ways, with or without auras. Other headaches can be of a more serious nature, associated with increased intracranial pressure, meningitis (viral or bacterial), and subarachnoid hemorrhage (SAH). Headaches such as migraines are called primary: these make up 90% of the presenting complaint, whereas the other 10% are called secondary and can be linked to increased morbidity and mortality.
When a clinician examines a patient with a headache, it is imperative that the SAH is always a part of the differential diagnosis. This is sometimes called the “don’t miss headache,” as missing the presenting signs and symptoms can lead to patient death. The untimely death of a patient is tragic both for those beloved and for those entrusted with his care. This tragedy, additionally, provides legal recourse for the family; litigation is certain. Defending this type of lawsuit is almost impossible because, too often, the clinician has not considered the SAH and has not ordered the appropriate tests. All headache patients should have a headache diary. This diary encourages a record of different types of headaches experienced in the past year. The headache diary consists of numerous factors that are suggested by the International Headache Society.
It has been said that 85% of diagnosis can be found in the patient’s history; therefore, the headache history must elicit specific responses that will lead the clinician to the proper potential diagnoses. A good headache history will discover the age of onset, frequency and duration, the site of the pain, quality of the pain, onset of the pain, aggravating factors and positions that exacerbate or relieve the pain. A physical exam follows and must include numerous body systems in order to properly determine a tentative diagnosis. The PA must first ask themselves: “Does this patient look sick?” This is a cardinal rule that transcends all other parts of the exam in all specialties. Is the patient febrile? Is he or she mentally alert? Are there any positive neurological signs and are the cranial nerves intact? Can the patient flex their head, does the patient have evidence of an ocular problem, are the reflexes normal and is there any dental pain such as TMJ? Is there an earache or any musculoskeletal signs such as neck pain? A careful review of systems and a good history will usually provide enough information to make a diagnosis.
When thinking of a secondary headache, we need to consider blood work, lumbar puncture, and sophisticated radiological tests. There will be times when you have the “gut feeling” that this might be a serious headache when you must immediately refer the patient to the ER and even have an ambulance transport the patient from your office or clinic. A missed diagnosis or failure to order appropriate tests, failure to refer to a neurologist or to the emergency department in a prompt manner, can lead to a worsening of the patient’s condition and to death. Each day that the physician assistant picks up a lab coat and stethoscope, he or she is preparing for the possibility of missing a diagnosis and harming a patient. It takes hundreds… thousands of patient encounters and, in most cases, many years to become an expert PA – but even experts can and do miss a diagnosis. Are you prepared for this eventuality? Are you insured for malpractice claims and who is the carrier? Is yours a claims-made or an occurrence policy? Is your policy presently in force or has someone decided that this might be a good year to skip the payment because of the economic crisis? Have you confirmed the annual renewal of your last issued policy? Is this a personal professional liability policy? Do you have a copy of your policy and, most importantly, are YOU named as the primary insured? These questions demand answers, and those answers are as important to your future as the patient history is to a proper diagnosis. If you are found to be personally liable, the inevitable outcome will spell career and financial disaster. Be prepared. Act today! Contact your professional organization, the AAPA or your state or local association and discover which carriers and policies they endorse and recommend. Don’t let your patient’s clinical headache become your legal headache.
By: Bob Blumm, PA-C Emeritus, DFAAPA
PA Advisor to CM&F