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E ditoria l
REVISTA PAULISTA DE MEDICIN AHe adache in an e me rge ncy room
• Isabela Martins Benseño r
In this issue o f the jo urnal, Bigal M, et al1 relate
their experience o f headache in the emergency ro o m o f the Ho spital o f the University o f São Paulo at Ribeirão Preto (São Paulo State), a tertiary care facility. They co n-clude that the ability to so lve simple cases o f headache at primary care units in this area is very lo w, and in co nse-quence a great number o f cases pro ceed to the tertiary care facility fo r medical diagno sis. This finding is at o dds with the quality o f medical care in this regio n o f the São Paulo State, which has an excellent physician/po pulatio n ratio and is stro ngly influenced by the Scho o l o f Medicine at USP-Ribeirão Preto . This paper, “Headache in an emergency room in Brazil” challenges us to discuss ho w to share the respo nsibility o f primary care units and high-tech ho spi-tals. In this case, the questio n is: Are headaches a pro b-lem fo r primary care physicians o r fo r neuro lo gists in a ho spital?
The first step to wards answering the questio n is to evaluate ho w co mmo n headaches are in Brazil. Few pa-pers have been published o n this, altho ugh the existing data sho w a prevalence rate as high as that o bserved in o ther co untries.2 The seco nd step is to evaluate ho w
se-vere the headache attacks are in Brazil. As the autho rs po inted o ut, mo st patients who so ught o ut the emergency ro o m had migraine, chro nic daily headache o r tensio n-type headache as their diagno sis. The final step is to evalu-ate the co st o f treatment at a primary care unit against the appro ach at an emergency ro o m. In rich co untries, e.g. the United States, where the fo cus o f medical care is o n high techno lo gy, the co st o f diagno stic pro cedures is in-creasing, but the quality is no t keeping pace.
Our co nclusio n is that mo st patients with headache must be assisted in a primary care setting. Ho wever, we need to discuss why the emergency ro o m is so attractive to mo st headache sufferers. We may speculate that shift-ing the co mplaint to the emergency ro o m is a co nsequence
o f a lack o f Family Physicians, General Practitio ners, Gen-eral Internal Medicine Specialists, o r using the Brazilian expressio n, “ Clínico s Gerais”. This kind o f physician can diagno ses and treats the majo rity o f headaches within no rmal clinical practice. This medical do cto r wo uld be a senio r physician, with great expertise o n the main guide-lines fo r treatment o f the mo st co mmo n diseases and with specializatio n in the treatment o f mino r sympto ms. No wa-days, many general practitio ners do no t have access to these main treatment guidelines. Equipping general prac-titio ners with these guidelines to be used in their ro utine activities will be a very impo rtant decisio n to make within the field o f public health.
In 1988, the Internatio nal Headache So ciety (IHS) distributed internatio nal criteria fo r the classificatio n o f headache, including the mo st co mmo n sympto ms in each type o f headache and the labo rato ry investigatio n neces-sary fo r the diagno sis o f primary and seco ndary headache.3
In this manual, the medical diagno sis o f primary head-ache is discussed. It is no ted that this is mo stly clinical and based o n the sympto ms that patients co mplain abo ut. Wide distributio n o f this manual can diminish the co st and impro ve the quality o f medical care. Only tho se pa-tients with co mplex headache o r suspected subarachno id hemo rrhage need to be transferred to ho spital to permit a bro ader neuro lo gical appro ach with mo re specific radio -lo gical o r labo rato ry investigatio n.
Returning to o ur starting po int, a wide-ranging dis-cussio n o n the mo st impo rtant guidelines in asso ciatio n with a co nsideratio n o f the mino r sympto ms can drasti-cally change the primary care diagno sis o f so me co m-plaints, leaving the mo re co mplicated cases to the spe-cialist, when bro ader investigative suppo rt is necessary.
Isabe la Martins Be nse ñor, MD, PhD. Assistant Physician, General Internal Medicine Unit, Ho spital das Clínicas, São Paulo .
1. Bigal M, bo rdini CA, Speciali JG. Headache in an emergency ro o m in Brazil. São Paulo Med J/Rev Paul Med 2000;118(3):58-62.
2. Bare a LM, Taanhause r M, Ro tta NT. An e pide mio lo gical study o f he ad ac he am o ng c hild re n and ad o le sc e nts in so uthe rn Brazil.
References
Cephalalgia 1996;16:545-9
3. He ad ac he Classific atio n o f the Inte rnatio nal He ad ac he So c ie ty. Classificatio n and diagno stic criteria fo r headache diso rders, cranial neuralgias and facial pain. Cephalalgia 1988;8:1-96, Supplement 7.
