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Headaches in ED

General Principles

  • The key to proper management is to make an accurate diagnosis.

  • Recognize the features of “dangerous” headaches, and know how to “rule out”.

IHS Diagnostic Classification

  • Primary Headache: 90%
  • Secondary Headaches: 10%


  • Headache Characteristics:
    • Temporal profile: acute vs chronic, frequency
    • Location and radiation
    • Quality
    • Alleviating and exacerbating factors
    • Associated symptoms
  • Constitutional symptoms
  • PMH: HTN, DM, hyperlipidemia, smoking

Physical Exam

  • Blood pressure
  • Fundoscopy
  • Auscultation for bruits in H/N
  • Temporal artery inspection and palpation
  • Meningismus
  • Neurologic exam: motor, sensory, coordination and gait

Acute onset headache

  • Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.
  • Sudden onset headache is a red flag

Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.

Life Threatening causes of acute headaches:

  • Intracranial hemorrhage
    • Subdural hemorrhage
    • Subarachnoid hemorrhage.
  • Meningitis
  • Hypertensive encephalopathy.

Subarachnoid hemorrhage:


  • 80% of non traumatic hemorrhages from ruptured saccular aneurysms.
  • Other causes: AV malformations, neoplasms, blood dyscrasias.
  • Commonest ages 40-60 yrs.

risk factors.

  • Estimated that 5% of population have a berry aneurysm.
  • HTN
  • Smoking and alcohol
  • Sympathomimetic drugs
  • Polycystic kidney disease
  • Coarctation of the aorta
  • Marfans syndrome.

useful signs and symptoms

  • Sudden onset of worst headache of life.
  • Worse on exertion eg valsalva, exercise.
  • 75% of patients have nausea and vomiting.
  • 50% of patients have meningism.
  • 25% of patients have neck stiffness.

Linn F et al: Prospective study of sentinel headache in aneurysmal subarachnoid hemorrhage, Lancet 344:590, 1994.

Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage, J Neurosurg 25:219, 1966.

Subdural hemorrhage

  • Dull, mild generalized head pain.
  • Symptoms of chronic SDH may be subtle.
  • Up to 50% have altered level of consciousness
  • Headache is worse at night and same side as hematoma
  • On exam patient may have unilateral weakness and increased reflexes.


useful signs and symptoms.

  • The absence of fever, neck stiffness and altered mental status in a patient with a headache virtually eliminates the diagnosis of meningitis.
  • In multiple studies the presence of neck stiffness on examination has a pooled sensitivity of 70%.
  • Does this adult patient have meningitis? Attia et al. JAMA 1999;281(2):175-181

Signs of Meningism.

  • In a prospective study of young adult patients Kernigs sign had a sensitivity of 9% and a specificity of 100%.
  • Brudzinskis sign has not been evaluated since the original report .

Uchihara T, Tsukagoshi H. Headache 1991;31:167-171.


Dr. Tariq Syed

Consultant in EM

University Hospital Birmingham