The role of urgent care centers in headache management: a quality improvement project

BACKGROUND: Patients with headache often seek urgent medical care to treat pain and associated symptoms that do not respond to therapeutic options at home. Urgent Cares (UCs) may be suitable for the evaluation and treatment of such patients but there is little data on how headache is evaluated in UC settings and what types of treatments are available. We conducted a study to evaluate the types of care available for patients with headache presenting to UCs. DESIGN: Cross-Sectional. METHODS: Headache specialists across the United States contacted UCs to collect data on a questionnaire. Questions asked about UC staffing (e.g. number and backgrounds of staff, hours of operation), average length of UC visits for headache, treatments and tests available for patients presenting with headache, and disposition including to the ED. RESULTS: Data from 10 UC programs comprised of 61 individual UC sites revealed: The vast majority (8/10; 80%) had diagnostic testing onsite for headache evaluation. A small majority (6/10; 60%) had the American Headache Society recommended intravenous medications for acute migraine available. Half (5/10) had a headache protocol in place. The majority (6/10; 60%) had no follow up policy after UC discharge. CONCLUSIONS: UCs have the potential to provide expedited care for patients presenting for evaluation and treatment of headache. However, considerable variability exists amongst UCs in their abilities to manage headaches. This study reveals many opportunities for future research including the development of protocols and professional partnerships to help guide the evaluation, triage, and treatment of patients with headache in UC settings

Neuropathic Otalgia: Rare and Treatable Ear Pains

Objective: To present two rare and commonly misdiagnosed causes of treatable neuralgic ear pain. Background: Ear pain (otalgia) is a common yet complex complaint which can be multifactorial in etiology. Receiving sensation from four cranial nerves (V, VII, IX and X), the upper cervical plexus and cervical sympathetic fibers, understanding the etiology of neuropathic otalgia – particularly greater auricular neuralgia and nervus intermedius neuralgia remains a difficult task in the clinical setting. Though the two present similarly, confirming the diagnosis is crucial in providing appropriate treatment. Design/Methods: We report 2 cases of neuropathic otalgia: First, a 55-year old female presented with severe, isolated right ear pain lasting 2 months involving the right mandibular angle and right carotid angle. Prior to neurologic evaluation, patient was misdiagnosed with otitis externa and treated with antibiotics with no improvement. Her initial work-up included contrasted MRI acoustic which was unremarkable. Her exam revealed exquisite tenderness over the right greater auricular nerve and lesser occipital nerve. In contrast, a 42-year-old male presented with post-traumatic right ear pain following a work-related accident with known skull fractures, subarachnoid and subdural hematomas 6 years prior to neurologic evaluation. Described as severe, stabbing, deep ear pain lasting for several seconds up to 1 minute with periods of remission lasting for months, concern for secondary nervus intermedius neuralgia prompted further evaluation with MRI acoustic and cervical spine. Results: Our first patient had dramatic improvement in her pain with greater auricular and lesser occipital nerve blocks, confirming the diagnosis of greater auricular neuralgia. Our second patient sought reassurance alone and declined any treatment with carbamazepine and gabapentin but continues to be monitored as an outpatient. Conclusions: Recognizing distinct clinical features based on pain characteristics, duration, and distribution of ear pain is an important diagnostic and therapeutic tool to identify uncommon causes of debilitating yet treatable ear pain