Overview of Headache in the Emergency Department


Key Chapter Points

About 2–3% of all ED visits are for headache. Migraine is the #1 diagnosis for nontraumatic headache seen in the emergency department, accounting for 40–60% of all nontraumatic, emergency department headaches. While migraine sufferers usually obtain routine headache care with outpatient providers, ED treatment is generally sought when pain becomes unbearable, patient’s current headache regimen is not effective, or a patient’s primary headache provider is unavailable. ED visits are expensive and often very frustrating for staff and patients. Common errors of ED headache assessment include focusing on identifying a specific primary headache diagnosis rather than distinguishing primary from secondary headaches, misunderstanding the role of hypertension, failing to identify unreported trauma, and using treatment response to confirm a diagnosis.


Acute migraine Cost Nausea Nontraumatic 


  1. 1.
    McCaig LF, Nawar EW. National Hospital Ambulatory Medical Care Survey. 2004 emergency department summary. Adv Data. 2006;372:1–29.PubMedGoogle Scholar
  2. 2.
  3. 3.
    American Board of Emergency Medicine website. Accessed Jun 2010.
  4. 4.
    Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. 2nd edition. Cephalalgia. 2004;24 Suppl 1:1–160.Google Scholar
  5. 5.
    Fiesseler FW, Riggs RL, Holubek W, Eskin B, Richman PB. Canadian Headache Society criteria for the diagnosis of acute migraine headache in the ED – do our patients meet these criteria? Am J Emerg Med. 2005;23:149–54.PubMedCrossRefGoogle Scholar
  6. 6.
    Goldstein JN, Camargo CA, Pelletier AJ, Edlow JA. Headache in the United States emergency departments: demographics, work-up and frequency of pathological disease. Cephalalgia. 2006;26:684–90.PubMedCrossRefGoogle Scholar
  7. 7.
    Friedman BW, Serrano D, Reed M, Diamond M, Lipton RB. Use of the emergency department for severe headache. A population-based study. Headache. 2009;49:21–30.PubMedCrossRefGoogle Scholar
  8. 8.
    Friedman D, Feldon S, Holloway R, Fisher S. Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department. Headache. 2009;49:1163–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Gupta MX, Silberstein SD, Young WB, et al. Less is not more: underutilization of headache medications in a university hospital emergency department. Headache. 2007;47:1125–33.PubMedCrossRefGoogle Scholar
  10. 10.
    Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med. 2008;51:714–22.PubMedCrossRefGoogle Scholar
  11. 11.
    Kuhn G, Goldberg R, Compton S. Tolerance of uncertainty, burnout, and satisfaction with the career of emergency medicine. Ann Emerg Med. 2009;54:106–13.PubMedCrossRefGoogle Scholar
  12. 12.
    Derlet RW, Ledesma A. How do prudent laypeople define an emergency medical condition? J Emerg Med. 1999;17:413–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Swadron SP. Pitfalls in the management of headache in the emergency department. Emerg Med Clin N Am. 2010;28:127–47.CrossRefGoogle Scholar
  14. 14.
    Vargas BB. Tension-type headache and migraine: two points on a continuum? Curr Pain Headache Rep. 2008;12:433–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Friedman BW, Hochberg ML, Esses D, et al. Applying the International Classification of Headache Disorders to the emergency department: an assessment of reproducibility and the frequency with which a unique diagnosis can be assigned to every acute headache presentation. Ann Emerg Med. 2007;49:409–19.PubMedCrossRefGoogle Scholar
  16. 16.
    Miner JR, Smith SW, Moore J, Biros M. Sumatriptan for the treatment of undifferentiated primary headaches in the ED. Am J Emerg Med. 2007;25:60–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Trainor A, Miner J. Pain treatment and relief among patients with primary headache subtypes in the ED. Am J Emerg Med. 2008;26:1029–34.PubMedCrossRefGoogle Scholar
  18. 18.
    Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev. 2010;4:CD008042.PubMedGoogle Scholar
  19. 19.
    Prokhorov S, Khanna S, Alapati D, Pallimalli SL. Subcutaneous sumatriptan relieved migraine-like headache in two adolescents with aseptic meningitis. Headache. 2008;48:1235–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Pfadenhauer K, Schönsteiner T, Keller H. The risks of sumatriptan administration in patients with unrecognized subarachnoid haemorrhage (SAH). Cephalalgia. 2006;26:320–33.PubMedCrossRefGoogle Scholar
  21. 21.
    Evans RW, Davenport RJ. Benign or sinister? Distinguishing migraine from subarachnoid hemorrhage. Headache. 2007;47:433–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Leira EC, Cruz-Flores S, Leacock RO, Abdulrauf SI. Sumatriptan can alleviate headaches due to carotid artery dissection. Headache. 2001;41:590–1.PubMedCrossRefGoogle Scholar
  23. 23.
    Manfredi PL, Shenoy S, Payne R. Sumatriptan for headache caused by head and neck cancer. Headache. 2000;40:758–60.PubMedCrossRefGoogle Scholar
  24. 24.
    Hodgson C, Roitberg-Henry A. The use of sumatriptan in the treatment of postdural puncture headache. Anaesthesia. 1997;52:808.PubMedGoogle Scholar
  25. 25.
    Ward TN, Levin M. Case reports: headache caused by a spinal cord stimulator in the upper cervical spine. Headache. 2000;40:689–91.PubMedCrossRefGoogle Scholar
  26. 26.
    Koul R, Chacko A, Javed H, et al. Syndrome of cerebrospinal fluid hypovolemia following lumbar puncture cerebrospinal fluid leak in a patient with idiopathic intracranial hypertension. J Child Neurol. 2002;17:77–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache. 2000;40:316–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Diaz M, Braude D, Skipper B. Concordance of historical questions used in risk-stratifying patients with headache. Am J Emerg Med. 2007;25:907–10.PubMedCrossRefGoogle Scholar
  29. 29.
    Baumann BM, Cline DM, Cienki JJ, et al. Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressures. Am J Hypertens. 2009;22:604–10.PubMedCrossRefGoogle Scholar
  30. 30.
    Karras DJ, Kruus LK, Cienki JJ, et al. Evaluation and treatment of patients with severely elevated blood pressure in academic emergency departments: a multicenter study. Ann Emerg Med. 2006;47:230–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Bigal ME, Kurth T, Santanello N, et al. Migraine and cardiovascular disease: a population-based study. Neurology. 2010;74:628–35.PubMedCrossRefGoogle Scholar
  32. 32.
    Gipponi S, Venturelli E, Rao R, Liberini P, Padovani A. Hypertension is a factor associated with chronic daily headache. Neurol Sci. 2010;31 Suppl 1:S171–3.PubMedCrossRefGoogle Scholar
  33. 33.
    Tanabe P, Persell SD, Adams JG, et al. Increased blood pressure in the emergency department: pain, anxiety, or undiagnosed hypertension? Ann Emerg Med. 2008;51:221–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of relationship between hypertension-associated symptoms and blood pressure in hypertensive ED patients. Am J Emerg Med. 2005;23:106–10.PubMedCrossRefGoogle Scholar
  35. 35.
    th report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Available at the National Heart, Lung, and Blood Institute website Accessed Jan 2011.
  36. 36.
    Ang SH, Chan YC, Mah M. Emergency department headache admission in an acute care hospital: why do they occur and what can we do about it? Ann Acad Med Sing. 2009;38:1007–10.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of PittsburghPittsburghUSA
  2. 2.Dean Health SystemsMadisonUSA

Personalised recommendations