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Evaluation of the adult with headache in the emergency department

F Michael Cutrer, MD
Section Editors
Robert S Hockberger, MD, FACEP
Jerry W Swanson, MD, MHPE
Deputy Editors
Jonathan Grayzel, MD, FAAEM
John F Dashe, MD, PhD


Patients with headache constitute up to 4.5 percent of emergency department (ED) visits [1,2]. The differentiation of the small number of patients with life-threatening headaches from the overwhelming majority with benign primary headaches (ie, migraine, tension, or cluster) is an important problem in the ED. Failure to recognize a serious headache can have potentially fatal consequences.

A careful history and physical examination remain the most important part of the assessment of the headache patient; they enable the clinician to determine whether the patient is at significant risk for a dangerous cause of their symptoms and what additional workup is necessary.

This topic will discuss how to approach adults presenting with headache in the ED with an emphasis on those components of the history and physical examination that characterize high-risk headaches. A flow chart to help guide this evaluation is provided (algorithm 1A-B). Detailed discussions of specific causes of headache are found elsewhere. (See "Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage" and "Headache, migraine, and stroke" and "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Acute treatment of migraine in adults" and "Preventive treatment of migraine in adults".)


The essential job of the emergency clinician is to determine which patients are at high-risk for a dangerous underlying cause of their headache. Such headaches are commonly referred to as secondary to distinguish them from benign intrinsic causes (ie, migraine, cluster, and tension), which are referred to as primary. The following historical features are warning signs to the presence of a secondary headache (table 1) [3].

Sudden onset — A severe persistent headache that reaches maximal intensity within a few seconds or minutes after the onset of pain warrants aggressive investigation [4,5]. Subarachnoid hemorrhage (SAH), for example, often presents with the abrupt onset of excruciating pain. Other serious etiologies of sudden-onset headache include carotid and vertebral artery dissections, venous sinus thrombosis, pituitary apoplexy, acute angle-closure glaucoma, and hypertensive emergencies (table 2). In contrast, migraine headaches generally begin with mild to moderate pain and then gradually increase to a maximal level over one to two hours.

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Literature review current through: Nov 2017. | This topic last updated: May 11, 2015.
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