• Emily Senecal, MD, Harvard Medical School, Boston Massachusetts
  • Last Updated: 2008



By the end of this module, the student will be able to

  • List the common causes of headache
  • List the emergent differential diagnosis of headache
  • Explain the importance of a complete neurological exam in the evaluation of all headache patients
  • Interpret laboratory studies for diagnosing meningitis and encephalitis
  • Explain the timing of antibiotic administration in suspected meningitis
  • Recognize and describe the head CT findings in subarachnoid hemorrhage, epidural hemorrhage, and subdural hemorrhage
  • Describe the time-sensitive treatment options for ischemic stroke
  • Discuss the ED work-up of first-time seizure and recurrent seizure
  • Explain the treatment of status epilepticus

Initial Actions and Primary Survey

As with all patients presenting to the Emergency Department, assessing ABCs is the first priority.  The majority of patients presenting to the ED with headache will not require immediate intervention of airway, breathing or circulation.

Primary survey should include a brief assessment for gross neurological deficit and an assessment of mental status.  Patients with headache and abnormal mental status may require immediate intervention.  Primary survey should also assess for signs or symptoms of CNS infection with sepsis.  Additionally, all patients presenting with headache following trauma should undergo full trauma assessment with cervical spine immobilization.

Secondary Survey

Obtaining a thorough history is crucial to differentiate causes of headache.  Seek to understand the circumstances of the onset of the pain: was the headache sudden or gradual onset?  Associated with activity/exertion or at rest? Aggravating or alleviating factors? Associated symptoms?  In particular, inquire about fever, neck pain and stiffness, photophobia, numbness or weakness in extremities or face, change in vision, speech, or gait, and nausea or vomiting, in addition to a standard review of symptoms. Many patients will report a history of prior headaches and be able to explain whether and how their current headache is different from prior.  Inquire about what treatments they have attempted at home, if any.   Inquire if others in the home have similar symptoms or if they recently started using the heater or furnace, both of which suggest carbon monoxide poisoning.

A thorough neurological exam is essential for all patients with headache.  Include testing of motor and sensory function, cranial nerves, reflexes, pronator drift, rapid alternating movements, finger-to-nose and heel-to-shin testing, Rhomberg test, gait assessment and mini mental status evaluation.  Perform a complete pupillary and fundoscopic exam to assess for asymmetric pupils, findings suggestive of acute angle closure glaucoma (minimally reactive mid-dilated pupils with ciliary flush), or findings suggestive of increased intracranial pressure (papilledema or loss of spontaneous venous pulsations).  In patients with possible temporal arteritis, assess for tenderness in the temporal area.

Differential Diagnosis

When assessing patients with headache, it is important to consider both the most common etiologies of headache, as well as the life-threatening etiologies of headache.

Common causes of headache

  • Tension headache
  • Migraine headache
  • Fever-associated headache
  • Sinusitis
  • Temporomandibular joint disease
  • Cluster headache
  • Trigeminal neuralgia

Emergent etiologies of headache

  • Subarachnoid hemorrhage
  • Epidural hemorrhage
  • Subdural hemorrhage
  • Intracranial hemorrhage
  • Stroke (although ischemic stroke uncommonly presents with headache)
  • CNS infection (meningitis/encephalitis/abscess)
  • CNS mass/increased intracranial pressure
  • Idiopathic intracranial hypertension (aka pseudotumor cerebrii)
  • Venous thrombosis
  • Carbon monoxide poisoning
  • Acute angle closure glaucoma
  • Temporal arteritis