UMEM Educational Pearls

Category: Neurology

Title: How Common are Headache and Back Pain Misdiagnoses?

Keywords: headache, back pain, misdiagnosis, stroke, intraspinal, epidural, abscess (PubMed Search)

Posted: 3/14/2019 by WanTsu Wendy Chang, MD (Updated: 7/5/2020)
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  • Misdiagnosis of neurologic emergencies can result in serious neurologic dysfunction or death.
  • A recent retrospective analysis using AHRQ databases looked at >3 million adults discharged from the ED with diagnoses of atraumatic headache or back pain.
  • A serious neurologic condition or death occurred within 30 days after ED discharge in:
    • 0.5% of patients with nonspecific diagnosis of headache
    • 0.2% of patients with nonspecific diagnosis of back pain
  • The frequency of adverse outcome was highest between days 1 and 3 after ED discharge.
  • The most frequent adverse outcome was ischemic stroke (18.1%) for headache and intraspinal abscess (44%) for back pain.
  • Age  85, male sex, non-Hispanic white, comorbidities such as neurologic disorders, HIV/AIDS, and malignancy were associated with higher incidence of adverse outcome.

Bottom Line: The rate of serious neurologic conditions missed at an initial ED visit is low.  However, the potential harm of misdiagnosis can be substantial.


Dubosh NM, Edlow JA, Goto T, Camargo CA, Hasegawa K. Missed serious neurologic conditions in emergency department patients discharged with nonspecific diagnoses of headache or back pain. Ann Emerg Med. 2019 Feb 21. [Epub ahead of print]
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