Seek Urgent Medical Evaluation Immediately
You should go to the emergency department or urgent care now—a severe headache lasting over 24 hours that does not respond to ibuprofen requires prompt diagnostic workup to exclude life-threatening causes such as subarachnoid hemorrhage. 1
Why This Requires Urgent Evaluation
The American Heart Association/American Stroke Association recommends that any patient with acute onset of severe headache undergo prompt diagnostic workup to diagnose or exclude aneurysmal subarachnoid hemorrhage (aSAH) and minimize morbidity and mortality. 1
Severe headache unresponsive to standard analgesics is a red-flag symptom that warrants immediate investigation, particularly when it persists beyond 24 hours. 1
The classic presentation of subarachnoid hemorrhage is a headache that is sudden in onset and reaches maximal intensity immediately, but 10% to 43% of cases are preceded by a "sentinel" or warning headache that may be less dramatic but still severe. 1
Misdiagnosis or delayed diagnosis of subarachnoid hemorrhage can have grave consequences, including death and severe disability. 1
What the Emergency Department Will Do
Immediate Diagnostic Workup
Non-contrast head CT is the mainstay of diagnosis and should be performed immediately upon arrival. 1
If you present more than 6 hours from symptom onset (which you have, since your headache has lasted over 24 hours), the American Heart Association recommends both a non-contrast head CT and, if negative, a lumbar puncture to diagnose or exclude subarachnoid hemorrhage. 1
If the CT is negative but clinical suspicion remains high, digital subtraction angiography (DSA) is indicated to diagnose or exclude cerebral aneurysm(s). 1
Additional Red-Flag Assessment
- The emergency physician will assess for other concerning features including:
If Serious Causes Are Excluded
First-Line Treatment for Severe Migraine
If imaging and examination rule out secondary causes, the American Academy of Family Physicians recommends ketorolac (Toradol) 30-60 mg IV/IM as the primary parenteral NSAID, with relatively rapid onset of action and approximately 6 hours of duration, making it ideal for severe migraine abortive therapy with minimal risk of rebound headache. 2
Metoclopramide 10 mg IV should be added, as it provides not only antiemetic effects but also synergistic analgesia for migraine pain through central dopamine receptor antagonism. 2
Prochlorperazine 10 mg IV is an alternative that effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy. 2
Oral Therapy for Home Management
If you are discharged home, the American College of Physicians recommends naproxen 500-825 mg plus a triptan (such as sumatriptan 50-100 mg) as first-line combination therapy for moderate to severe migraine. 2
This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 2
Critical Medication-Overuse Prevention
Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 2
If you require acute treatment more than twice weekly, preventive therapy should be initiated immediately rather than continuing frequent acute medication use. 2
Common Pitfalls to Avoid
Do not delay seeking care because you hope the headache will resolve on its own—severe headache unresponsive to ibuprofen for over 24 hours is not typical of benign primary headache and requires investigation. 1
Do not take additional doses of ibuprofen beyond recommended limits (maximum 2400 mg/day), as this increases toxicity risk without improving efficacy and can lead to medication-overuse headache. 2
Avoid opioids (such as codeine, hydrocodone, or oxycodone) for headache treatment, as they have limited efficacy, carry substantial risk of dependence, and can cause rebound headaches. 2
Bottom Line
Go to the emergency department now. A severe headache lasting over 24 hours that has not responded to ibuprofen requires urgent evaluation to exclude subarachnoid hemorrhage and other life-threatening causes. 1 Once serious causes are ruled out, effective treatments are available, but the first priority is ensuring this is not a medical emergency. 1