This page is for adult patients. For pediatric patients, see: headache (peds)
- Headache accounts for ~2.2% of all ED visits
- The majority of these have a benign cause, but serious causes can be devastating, and a thorough H&P with an eye toward "red flag" symptoms is important in ED evaluation.
- When red flags are excluded, may attempt to define a common primary headache syndrome, but this is not an ED priority
Headache Red Flags
- Sudden onset or accelerating pattern
- Maximum intensity of pain at onset (i.e. "thunderclap")
- Worse with valsalva
- Worse in the morning or at night
- No similar headache in past
- Age >50 yr or <5 yr
- Occipitonuchal headache
- Visual disturbances
- Exertional or postcoital
- Family or personal history of SAH, cerebral aneurysm, or AVM
- Focal neurologic signs
- Diastolic BP >120
- Jaw claudication
Headache in setting of:
- Altered mental status
- Systemic illness (fever, stiff neck, rash)
- Patient on anticoagulation, steroids, NSAIDs, antiplatelet
- Time to maximal onset
- Triggers, auras, visual change, neuro symptoms, or systemic symptoms
- Medication over-use, caffeine use, substance use, blood thinner uses
- Prior headache history and any specialists seen
- New-onset headache is generally more concerning
- Scalp and temporal artery palpation
- Neuro exam
- HEENT and dental exam
- Evaluate for meningismus
- Sinus tap / transillumination
- EBQ: Jolt Test
- Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
- Although a 1991 study showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- Carbon monoxide poisoning
- Basilar artery dissection
- Cerebral venous thrombosis
- Hypertensive emergency
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
- Lyme disease
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- If suspect temporal arteritis → ESR
- If suspect meningitis → CSF studies
- Cannot use CBC to rule-out meningitis
- Add India Ink, cryptococcal antigen if suspect AIDS-related infection
- If suspect CO poisoning → carboxyhemoglobin level
- If concern for ICH → non-contrast CT Brain ± Lumbar puncture
- Consider non-contrast head CT in patients with:
- Thunderclap headache
- Worst headache of life
- Different headache from usual
- Meningeal signs
- Headache + intractable vomiting
- New-onset headache in patients with:
- Age > 50yrs
- Neurological deficits (other than migraine with aura)
- Consider CXR
- Consider CTA head and neck for headaches associated with head/neck trauma or neuro deficits
- Consider Brain MRI for red flag symptoms with a negative CT head
- Consider MRV to evaluate for cerebral venous thrombosis for headache in the setting of hypercoagulability
If known, treat specific headache type; avoid opioid medications if at all possible
- 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L IVF bolus
- Acetaminophen IV or PO, 325-1000 mg
- Ketorolac 10-30 mg IV (30-60mg IM)
- Lower doses are shown to be just as effective
- Sumatriptan most effective within 6 hours of headache onset
- Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
- 6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
- OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
- OR 1-2 sprays IN (may repeat after 2 hours)
- Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
- Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches
Other 2nd and 3rd Line Options
- Magnesium 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks
- Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)
- Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms
- Perform EKG monitoring for patients at risk of QTc prolongation
- Do not give to patients who take already multiple QT prolonging drugs
- Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications
- Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy
- Particularly useful in psych patients with mania, BPD, psychosis
- IV olanzapine may be as safe or safer than IM, with faster onset
- Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth
- Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process
- Sphenopalatine ganglion block
- Great for patients without an IV
- 10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes 
- Consider greater occipital nerve block
- For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness 
- Severe, intractable status migrainosus may benefit from off-label IV propofol
- Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
- Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
- Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg
- Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
- Average dosage required ~100-125 mg
- Outpatient referral to primary care or neurology for recurrent, recalcitrant headaches
- Admission for status migrainosus or dangerous underlying etiology
- DDxOf: Differential Diagnosis of Headache
- ACEP Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache
- Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36. doi: 10.1016/j.annemergmed.2008.07.001.
- Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
- Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
- Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
- Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
- Friedman BW, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of EM. January 2016. 67(1):32-39.
- Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.
- Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Diener HC. Cephalalgia. 1999 Jul; 19(6):581-8; discussion 542.
- Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
- Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
- Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
- Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
- Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.
- Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
- Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
- Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
- Sin B et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7.
- Mellick LB et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.
- The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
- Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
- Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.
- Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.