Next Step: Discharge with Follow-Up Planning
For a patient with subsided pain and no neurological deficits, headache, nausea, vomiting, or dizziness, the next step is discharge with structured follow-up and clear return precautions.
Immediate Management
Since the patient's pain has resolved and there are no concerning neurological symptoms, they have met criteria for safe discharge. However, this must be accompanied by specific safety planning:
Discharge Instructions Must Include 1:
Written documentation (dated) containing:
- Complete medication list with descriptions of what each medication is for and exact instructions for timing and dosing
- List of potential side effects and specific actions to take if they occur
- List of all medications to discontinue
- Emergency contact numbers with specific instructions to call for:
- New pain or change in pain character
- Pain not relieved with prescribed medication
- Nausea/vomiting preventing eating for 24 hours
- No bowel movements for 3 days (if on opioids)
- Difficulty arousing from sleep during daytime
- Confusion or altered mental status
- Any neurological symptoms (weakness, numbness, vision changes)
Critical Return Precautions
Instruct the patient to return immediately for 2, 3:
- Thunderclap headache (sudden, severe "worst headache of life")
- Focal neurological deficits (weakness, numbness, speech changes)
- Altered consciousness or personality changes
- Neck stiffness with fever
- Headache worsening with position changes, coughing, or straining
- New visual disturbances
- Seizure activity
Follow-Up Planning
Schedule or arrange 1:
- Follow-up visit or phone call within 1-2 weeks to reassess symptom control
- Referral to appropriate specialist if this was a primary headache disorder (neurologist or headache center) - this is critical as lack of specialist referral leads to high ED relapse rates 4
- Pain management specialist if chronic pain condition
Medication Reconciliation
Before discharge, verify 1:
- Patient understands how to take each prescribed medication
- Patient has no concerns about obtaining or affording medications
- Patient understands not to self-adjust dosages
- Patient knows not to mix medications with alcohol or illicit substances
- Controlled substances are properly safeguarded at home
- Patient understands risks of frequent analgesic use leading to medication overuse headache
Common Pitfalls to Avoid
Do not discharge without:
- Written instructions (verbal alone is insufficient)
- Confirming patient understanding of return precautions
- Addressing medication access/cost concerns
- Scheduling definitive follow-up
Avoid assuming the patient knows when to return - be explicit about red flag symptoms that warrant immediate re-evaluation.
The evidence consistently emphasizes that communication and structured follow-up are critical components of safe discharge 1. Patients cannot self-assess their condition adequately without clear guidance, and healthcare providers must proactively establish these safety parameters rather than assuming patients will know when to seek additional care.