What is the recommended approach to evaluating and managing a patient with a new or worsening headache in the emergency department of a primary care hospital?

Emergency Department Approach to Headache in Primary Care Hospitals

The first priority in the ER is to rapidly identify and rule out life-threatening secondary causes through red flag assessment and urgent neuroimaging when indicated, before considering any symptomatic treatment. 1

Immediate Red Flag Assessment

Any patient presenting with the following features requires urgent neuroimaging before treatment:

• "Thunderclap" or sudden-onset severe headache – suggests subarachnoid hemorrhage and mandates immediate CT head without contrast 1, 2
• Headache worsening with lying down or Valsalva maneuver – indicates possible increased intracranial pressure 1, 3
• Focal neurological deficits (weakness, sensory changes, visual disturbances, altered mental status) – suggests stroke, hemorrhage, or mass lesion 1, 2
• Headache awakening patient from sleep or progressively worsening pattern – concerning for secondary pathology 1, 3
• New-onset headache after age 50 – higher likelihood of secondary cause as primary headaches typically remit with age 1, 4
• Significant change in established headache pattern – requires urgent evaluation even in known headache patients 1, 2
• Papilledema, neck stiffness, fever, or immunocompromised state – suggests infection, increased pressure, or meningitis 2
• Headache after head trauma 2

Neuroimaging Protocol

CT head without contrast is the first-line study in the acute ER setting, especially when subarachnoid hemorrhage is suspected, as it rapidly detects acute bleeding 1

MRI brain with and without contrast is preferred when available for persistent headaches, as it provides superior detection of masses, ischemia, and structural abnormalities 1

Lower your threshold for imaging in patients over 50 years with new headaches, even without classic red flags 1, 4

If CT/MRI is normal but subarachnoid hemorrhage remains suspected, perform lumbar puncture for CSF analysis to detect xanthochromia 1, 3

Management When Red Flags Are Absent

For Acute Migraine Treatment in the ER:

First-line acute therapy:

• NSAIDs (ibuprofen, diclofenac potassium, or aspirin) for mild-to-moderate headache without vomiting 5
• Avoid acetaminophen alone as it has limited efficacy; use only if NSAIDs contraindicated 5

Second-line acute therapy:

• Triptans for moderate-to-severe migraine or when NSAIDs fail 5
• Administer early when headache is still mild for maximum effectiveness 5
• Subcutaneous sumatriptan for rapid peak intensity or vomiting patients 5
• Exercise caution with triptans in women over 50 due to cardiovascular risk 4

Parenteral options for severe cases:

• Ketorolac (parenteral NSAID) has rapid onset and 6-hour duration, with low rebound risk 5
• Avoid opioids (meperidine, butorphanol) except as last resort, as they cause dependency and medication-overuse headache 5

Critical Medication Overuse Warning:

Monitor for medication-overuse headache thresholds:

• Triptans/ergots/combination analgesics: ≥10 days/month for ≥3 months 6
• Simple analgesics: ≥15 days/month for ≥3 months 6

Disposition and Follow-Up Planning

Discharge with preventive therapy consideration if:

• Headaches occur ≥15 days/month for >3 months (chronic migraine criteria) 6, 4
• Significant functional impairment despite adequate acute treatment 6
• Approaching medication-overuse thresholds 6

Preventive medication options for outpatient initiation:

• Topiramate 50-100 mg daily as first-line prophylaxis 1, 4
• Alternative options: amitriptyline, beta-blockers, or candesartan 1, 4
• Avoid valproate in women of childbearing age due to teratogenic effects 1, 4

Refer to neurology if:

• Uncertain diagnosis despite negative workup 5
• Persistent headache unresponsive to standard therapy 5
• Chronic migraine requiring specialist management 5

Common Pitfalls to Avoid

Do not skip neuroimaging based solely on "normal exam" – atypical features or red flags mandate imaging regardless 5, 1

Do not assume chronic headache pattern equals benign cause – new symptoms in chronic headache patients require full re-evaluation 1, 3

Do not prescribe opioids routinely – they worsen long-term outcomes through dependency and rebound 5

Do not discharge without addressing medication overuse – patients using acute medications frequently need preventive therapy and medication withdrawal planning 5, 6