Short-term Stroke Risk After Emergency Department Treat-and-release Headache Visit

Ava L. Liberman MD; Cenai Zhang MS; Richard B. Lipton MD, MS; Hooman Kamel MD, MS; Neal S. Parikh MD, MS; Babak B. Navi MD, MS; Alan Z. Segal MD; Junaid Razzak MD; David E. Newman-Toker MD, PhD; Alexander E. Merkler MD, MS


Headache. 2022;62(9):1198-1206. 

In This Article

Abstract and Introduction


Objective: To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke.

Background: Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error.

Methods: We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005–2018 and New York 2005–2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities.

Results: We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29–3.16) or back pain (HR: 4.0; 95% CI: 3.74–4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22–1.78) or back pain (HR: 1.49; 95% CI: 1.24–1.80).

Conclusion: Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.


Missed emergency department (ED) diagnosis of dangerous cerebrovascular disease, particularly among patients presenting with mild or transient neurological symptoms, is a well-recognized public health issue estimated to occur in approximately 9% of all stroke patients.[1,2] Headache complaints account for a substantial proportion of national ED visits.[3,4] While the majority of headache complaints evaluated in the emergency setting are benign,[4] an estimated 40,000 patients per year in the United States suffer adverse neurological events shortly after an ED headache visit resulting in discharge to home.[5] Given that a variety of cerebrovascular conditions can manifest mainly as headache[4,6,7] and that differentiating transient cerebral ischemia from migraine aura symptoms can be challenging,[8] failure to accurately diagnose high-risk cerebrovascular events manifesting as headache may occur.

In this analysis, we evaluate whether ED headache visits that result in discharge to home are associated with a heightened risk of short-term stroke hospitalization and thus are suggestive of probable diagnostic error at index ED visit.[9] We hypothesized that patients with an ED visit for headache would have a higher risk of stroke compared to patients with an ED visit for conditions not typically associated with stroke missed diagnosis: renal colic and back pain.[5,10]