title: Isolated headache in general practice: determinants for delay in referral in patients with subarachnoid haemorrhage.
abstract: BACKGROUND
  A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom.
  
  
  OBJECTIVE
  To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP).
  
  
  METHODS
  For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (> 2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs).
  
  
  RESULTS
  Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral.
  
  
  CONCLUSIONS
  In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.
authors.affiliation: Department of Neurology, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands. visser.femke@gmail.com
authors.forename: Femke
authors.initials: F
authors.lastname: Visser
authors.forename: Gabriel J E
authors.initials: GJ
authors.lastname: Rinkel
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D016001:Confidence Intervals; D057210:Delayed Diagnosis; D005260:Female; D058006:General Practice; D006261:Headache / Q000175:diagnosis* / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D012017:Referral and Consultation; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000175:diagnosis*; D013997:Time Factors