Acute Headache in the Emergency Department

  • Dominique Valade
  • Anne Ducros
  • Susan W. Broner
Reference work entry


In emergency departments, the top priority is to establish a precise etiologic diagnosis and to classify the headache as a primary headache, a benign secondary headache, such as from influenza, or a secondary headache due to a serious condition, requiring further exploration or emergency treatment (meningeal hemorrhage, meningitis, intracranial hypertension, amongst others). The crucial part of this diagnostic step is the interview. This step, supplemented by the clinical examination, will determine the differential diagnosis and, ultimately, will steer any tests that need to be done emergently and the course of treatment. Depending on the headache diagnosis, the patient may be treated and released for outpatient follow-up or may need to be admitted to the hospital for either further evaluation and/or treatment.

The physician must also identify headaches occurring in patients already hospitalized for another reason. It is important to rule out any iatrogenic causes such as drug induced headaches or headaches caused by hypotension of the cerebral spinal fluid (CSF) such as secondary to a persisting fistula after lumbar puncture or other procedure that enters into the CSF space.

Finally, some patients diagnosed with a primary headache may sometimes require hospitalization either because of an acute exacerbation of their primary headache in a particular psychological context, or, especially, for detoxification for chronic daily headache associated with medication overuse.


Cluster Headache Lumbar Puncture Intracranial Hypertension Cerebral Spinal Fluid Medication Overuse 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Arnold M, Cumurciuc R, Stapf C, Favrole P, Berthet K, Bousser MG (2006) Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry 77:1021–1024PubMedCrossRefGoogle Scholar
  2. Benzon HT, Iqbal M, Tallman MS, Boehlke L, Russell EJ (2003) Superior sagittal sinus thrombosis in a patient with postdural puncture headache. Reg Anesth Pain Med 28:64–67PubMedGoogle Scholar
  3. Berroir S, Loisel B, Ducros A, Boukobza M, Tzourio C, Valade D, Bousser MG (2004) Early epidural blood patch in spontaneous intracranial hypotension. Neurology 63:1950–1951PubMedGoogle Scholar
  4. Boulan P, Ducros A, Berroir S, and Bousser MG (2004) Les céphalées aiguës. In: Niclot P, Amarenco P (eds) Urgences neurologiques. Puteaux, Da Te Be, pp 13–26Google Scholar
  5. Bourrier P, Perroux D, Lannehoa Y, Thomas O (2001) Epidémiologie des céphalées de l'adulte dans les services d'urgences. In: Bourrier P (ed) Céphalées en urgence. Paris, Masson, pp 3–10Google Scholar
  6. Chen SP, Fuh JL, Lirng JF, Chang FC, Wang SJ (2006) Recurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder? Neurology 67:2164–2169PubMedCrossRefGoogle Scholar
  7. Colman I, Brown MD, Innes GD et al (2004) Parenteral metoclopramide for acute migraine: meta-analysis of randomized controlled trials. Br Med J 329:1369CrossRefGoogle Scholar
  8. Cortelli P, Cevoli S, Nonino F, Baronciani D, Magrini N, Re G, De Berti G, Manzoni GC, Querzani P, Vandelli A (2004) Evidence-based diagnosis of nontraumatic headache in the emergency department: a consensus statement on four clinical scenarios. Headache 44:587–595PubMedCrossRefGoogle Scholar
  9. Cumurciuc R, Crassard I, Sarov M, Valade D, Bousser MG (2005) Headache as the only neurological sign of cerebral venous thrombosis: a series of 17 cases. J Neurol Neurosurg Psychiatry 76:1084–1087PubMedCrossRefGoogle Scholar
  10. Dhopesh V, Anwar R, Herring C (1979) A retrospective assessment of emergency department patients with complaint of headache. Headache 19:37–42PubMedCrossRefGoogle Scholar
  11. Dickman RL, Masten T (1979) The management of non-traumatic headache in a university hospital emergency room. Headache 19:391–396PubMedCrossRefGoogle Scholar
  12. Dodick DW, Wijdicks EF (1998) Pituitary apoplexy presenting as a thunderclap headache. Neurology 50:1510–1511PubMedGoogle Scholar
  13. Fodden DI, Peatfield RC, Milsom PL (1989) Beware the patient with a headache in the accident and emergency department. Arch Emerg Med 6:7–12PubMedGoogle Scholar
  14. Friedman BW, Corbo J, Lipton RB et al (2005) A trial of metoclopramide vs. sumatritpan for the emergency department treatment of migraines. Neurology 64:463–468PubMedCrossRefGoogle Scholar
  15. Gordon-Bennett P, Ung T, Stephenson C, Hingorani M (2006) Misdiagnosis of angle closure glaucoma. Br Med J 333:1157–1158CrossRefGoogle Scholar
  16. Kao LW, Nanagas KA (2006) Toxicity associated with carbon monoxide. Clin Lab Med 26:99–125PubMedCrossRefGoogle Scholar
  17. Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I (2002) Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia 22:354–360PubMedCrossRefGoogle Scholar
  18. Leicht MJ (1980) Non-traumatic headache in the emergency department. Ann Emerg Med 9:404–409PubMedCrossRefGoogle Scholar
  19. Linn FH, Wijdicks EF, van der Graaf Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J (1994) Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 344:590–593PubMedCrossRefGoogle Scholar
  20. Linn FH, Rinkel GJ, Algra A, van Gijn J (1998) Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 65:791–793PubMedCrossRefGoogle Scholar
  21. Lledo A, Calandre L, Martinez-Menendez B, Perez-Sempere A, Portera-Sanchez A (1994) Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache 34:172–174PubMedCrossRefGoogle Scholar
  22. Luda E, Comitangelo R, Sicuro L (1995) The symptom of headache in emergency departments. The experience of a neurology emergency department. Ital J Neurol Sci 16:295–301PubMedCrossRefGoogle Scholar
  23. Morgenstern LB, Luna-Gonzales H, Huber JC Jr, Wong SS, Uthman MO, Gurian JH, Castillo PR, Shaw SG, Frankowski RF, Grotta JC (1998) Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 32:297–304PubMedGoogle Scholar
  24. Newman LC, Lipton RB (1998) Emergency department evaluation of headache. Neurol Clin 16:285–303PubMedCrossRefGoogle Scholar
  25. Prager JM, Mikulis DJ (1991) The radiology of headache. Med Clin North Am 75:525–544PubMedGoogle Scholar
  26. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL (1997) Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 54:1506–1509PubMedGoogle Scholar
  27. Schwedt TJ, Dodick DW (2006) Thunderclap stroke: embolic cerebellar infarcts presenting as thunderclap headache. Headache 46:520–522PubMedCrossRefGoogle Scholar
  28. Schwedt TJ, Matharu MS, Dodick DW (2006) Thunderclap headache. Lancet Neurol 5:621–631PubMedCrossRefGoogle Scholar
  29. Shahien R, Saleh SA, Bowirrat A (2010) Intravenous valproate sodium (Orfiril i.v.) aborts migraine headaches rapidly. Acta Neurol ScandGoogle Scholar
  30. Shrestha M, Singh R, Moreden J et al (1996) Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A Prospective, randomized, double blind trial. Arch Intern Med 156(15):1725–1728PubMedCrossRefGoogle Scholar
  31. Silberstein SD (1992) Evaluation and emergency treatment of headache. Headache 32:396–407PubMedCrossRefGoogle Scholar
  32. Stevenson RJ, Dutta D, MacWalter RS (1998) The management of acute headache in adults in an acute admissions unit. Scott Med J 43:173–176PubMedGoogle Scholar
  33. Swidan SZ, Lake AE III, Saper R JR (2005) Efficacy of intravenous diphenhydramine versus intravenous Swidan SZ, Lake AE III, and R. Saper JR. Treatment of severe migraine headache. Curr Pain Headache Rep 5(1):65–70CrossRefGoogle Scholar
  34. Valade D (2006) Headache in the emergency room. In: Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welch KMA (eds) The headaches. Lippincott Williams & Wilkins, Philadelphia, pp 1133–1138Google Scholar

Copyright information

© Lifting The Burden 2011

Authors and Affiliations

  • Dominique Valade
    • 1
  • Anne Ducros
    • 2
  • Susan W. Broner
    • 3
  1. 1.Emergency Headache CenterLariboisière Hospital, Assistance Publique des Hôpitaux de ParisParisFrance
  2. 2.Centre Urgences CéphaléesAssistance Publique des Hôpitaux de Paris, Head and Neck Clinic, Hôpital LariboisièreParisFrance
  3. 3.The Headache InstituteSt. Luke's-Roosevelt HospitalNew YorkUSA

Personalised recommendations