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Federal Administrative Actions Impact MPL

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Inside Medical Liability

Fourth Quarter 2019

 

 

RISK MANAGEMENT

Is It Migraine . . . or Something Worse?

29-year-old woman came to a community hospital emergency room, complaining of troubling symptoms: severe headache, vomiting, and diminished consciousness.

BY DANA MURPHY

 
The nurses and ER physician at the facility failed to obtain critical information from her: when and how the headache began, its intensity, and how it compared with other headaches she’d had in the past.

This information is critical to making an accurate diagnosis, and, in particular, ruling out a head bleed (hemorrhage). The defendant nurses and the doctor claimed that the woman had refused to speak further with them. But the two nurses admitted that, in fact, they had an independent duty to obtain the historical information.

The emergency department doctor had no sound basis for ruling out a head bleed, and organic disease should always be ruled out before a migraine diagnosis can be made. The American College of Emergency Physicians policy states that the emergency department physician must order a CT scan for any patient who presents with recurrent vomiting or a change in headache pattern. CT scanning is highly reliable for detecting subarachnoid hemorrhage.

As it was, the patient was sent home, and she subsequently suffered a second major bleed. The damages awarded to her totaled $3 million.

Getting to the root cause

A complete and accurate diagnosis of a patient with severe headache requires a full neurological and general medical examination (American Headache Society, 2011). The first step is to exclude any potentially serious conditions, like a brain bleed, that may be the root cause of the headache. Each patient, and each instance, needs to be thoroughly analyzed; the clinical features of secondary headaches can be virtually indistinguishable from what’s seen with primary headaches. Further complicating matters is the fact that the full differential diagnosis is extraordinarily diverse.

When a headache is episodic and recurrent and also follows a well-established pattern, the patient may have a primary headache disorder. But there are some important symptoms that differentiate migraine from other kinds of primary headache disorders and, ultimately, point to the optimal treatments.

Symptoms of secondary headache disorder could include:
  • The worst headache of the patient’s life, especially if it came on rapidly
  • A change in frequency, severity, or clinical features of the attack
  • A new progressive headache that persists for days
  • A headache accompanied by stiff neck or fever.
The classic presentation for intracranial aneurysms in particular might include:
  • A severe headache, with sudden, explosive onset
  • Stiff neck
  • Photophobia
  • Nausea and vomiting
  • Possibly, alteration of consciousness.
These symptoms necessitate an extensive evaluation: CT scan of the head and then lumbar puncture if the scan is negative. However, there are no firm conclusions in the medical literature, at this point, about whether an angiogram should be done as well.

But then, there are all the other suspects that could be causes of severe headaches. In patients with space-occupying lesions (for example, primary or metastatic brain tumors), headache has been reported by 48% of patients. The headache most closely resembled a migraine in 9% of patients and tension- type headaches in 77% (J. Chawla et al, Medscape, January 30, 2018).

Any patient who has a history of headache should have a full diagnostic work- up if the current headache differs in any substantial way from his or her usual headache (J. Chawla et al, Medscape, January 30, 2018) The same is true if any of the other causes of secondary headache are considered, notably, spontaneous internal carotid dissection, headaches in patients over 50 (to consider temporal or giant cell arteritis.

Migraine and stroke

Despite 40 years of observations suggesting some sort of linkage, there are still no firm conclusions—and even less certainty about possible pathogenic mechanisms—about the relationship between migraine and stroke. But one study, done in Sweden, aimed at minimizing the confusion by using sets of twins as the study population. The researchers also checked to see if familial factors were contributing to any increased risk they observed. The twins who were included in the study population had had no prior cerebrovascular disease.

In total, 8,635 twins had a migraine headache: 3,553 had migraine with aura and 5,082 had non-aura migraine headache (including migraine without aura and probable migraine), and 44,769 twins had no migraine. During a mean follow-up time of 11.9 years, there were 1,297 incident cases of stroke.

The authors concluded that there had been no increased stroke risk related to migraine overall, although there was a modestly increased risk for stroke related to migraines that included visual aura, and within-pair analyses suggested that familial factors might contribute in a minor way to this association.

Potential liability

The complexity of migraine diagnosis and the possibility for error leaves clinicians exposed to liability. In fact, a personal injury attorney’s blog includes an article on headaches and migraines. “If you are injured because a doctor or other medical professional incorrectly diagnosed your condition as a migraine when it was something more serious, you may have grounds to file a medical malpractice claim,” writes the lawyer. The article goes on to caution that even if a migraine was diagnosed properly, there’s a good chance that some clinician gave the wrong medicine. “For example,” writes the author, “narcotics are not supposed to be given as ‘first-line’ treatments for migraines. Rather, these medications are only to be given as a last resort. However, in many cases, patients are prescribed narcotics which are addictive, have withdrawal symptoms, and can make migraines in the long run.”

A ruling in California illustrates the risks of the difficulty of misdiagnosis of migraine. On March 2012, a jury handed down a $22 million verdict against a medical clinic in California. What had happened? Doctors of a 43-year-old woman seeking a treatment for migraines performed a cerebral angiogram to investigate an abnormal vein in her brain. She reacted badly to the procedure, suffering a stroke that paralyzed her on her right side— after enduring a coma that had lasted six weeks—and was unable to speak.

The lawsuit alleged that she was not told that the procedure was invasive and risky. Further, witnesses for the plaintiff stated that the cerebral angiogram was not necessary and did not provide any benefit. Nothing could be seen on this test that wasn’t already apparent on the noninvasive tests.

Plaintiff ’s law firms are also on the look- out for clients whose stroke has (putatively) been misdiagnosed as, most frequently, a migraine. One law firm’s website states that, “We can divide medical malpractice cases involving strokes into two categories: those that could have been prevented if the proper care had been provided and those that were directly caused by negligence.

Some specific examples of the types of scenarios we can address include:
  • Failure to diagnose the possibility of a stroke by conducting proper tests to recognize blockage by blood clots;
  • Misdiagnosis of stroke as another medical condition and subsequent failure to properly treat . . .”

How providers can protect themselves

Recognizing the complexities of migraines and the possibilities of serious underlying root causes are key to proper diagnosis—and defense against possible MPL claims. One plaintiff ’s lawyer writes in a blog posting that, “Medical care professionals should conduct a thorough exam when a patient complains of stroke symptoms, which may include checking blood pressure and/or ordering testing including a carotid duplex ultrasound; a head angiogram; a CT; an MRI; an echocardiogram; and a magnetic resonance angiography or MRA.” (www.coplancrane.com).

Note that the tests that differentiate migraine from stroke are basically the same as those that are appropriate for zeroing in on a head bleed:
  • a CT scan
  • An MRI scan
  • An angiogram
  • Blood tests that can identify immune system disorders, inflammation, and blood clotting problems that can cause bleeding in the brain.
In short, there is no reason to forgo a full diagnostic workup for a patient who presents with symptoms that could indicate a migraine—or something considerably more serious. And there is every reason, defensively speaking, to perform the workup, as quickly as possible.

 

 
    Dana Murphy is editor of Inside Medical Liability.