This document provides guidance on evaluating patients presenting to the emergency department with headaches. It emphasizes taking a thorough history including details on headache onset, progression, severity and associated symptoms. The examination should include a neurological exam checking cranial nerves, eye movements, and sensation. Common differential diagnoses are discussed like subarachnoid hemorrhage, meningitis, migraine and tension headaches. Recommended workup depends on risk factors and may include CT, MRI or lumbar puncture. Special considerations for pediatric patients are also reviewed.

1. Evaluation of headache in the ED
Dima Lotfie
13901022

2. • Patients with headaches constitute up to 4.5% of ED visits.
• Most of them are benign headaches
• How to avoid missing serious conditions?
• History and examination
• Differential diagnosis
• Work up

3. A patient with headache in the ED: History taking
• SOCRATES
• Focus on:
1. Onset (when and how)
2. Progression: “was it the worst when it started? Did it get any better
or worse?”
3. Severity: “how do you compare the severity of this headache to
other headaches you had in the past?”
• These questions will narrow down your differential and guid you to a
diagnosis.
• Red flags of subarachnoid hemorrhage.

4. A patient with headache in the ED: History taking
• Associated symptoms like photophobia,
phonophobia vomiting, visual changes,
syncope, speech difficulty, dizziness, neck
pain or fever.
• Past history/prior evaluation by a
neurologist
• Previous head imaging: can exclude a
mass causing the headache.

5. A patient with headache in the ED: Examination
• A brief neurological examination: make sure you cover all the
important findings you need to rule out serious conditions.
• Head to toe:
o Speech
o HMFs
o Cranial nerves (briefly):
o 2nd: pupillary reflexes, papilledema.
o 3rd, 4th and 6th : eye movements (check for nystagmus)
o5th : facial sensation
o7th : elevate eyebrows, smile, puff cheeks.

6. A patient with headache in the ED: Examination
• Neck: for meningisim
• Limbs: tone and power
• Cerebellar examination: finger nose test, heel shin test, gait.
• Sensory

7. Differential Diagnosis
1. Subarachnoid hemorrhage: sudden + maximal at onset + worst
severity.
2. Bacterial meningitis/ encephalitis: fever + ill patient + neck stiffness
3. Temporal arteritis: elderly + unilateral throbbing temporal or forehead
headache + tenderness on a palpable cord like temporal artery.
4. Carbon monoxide poisoning: suspected if many members of the
family have headache, cold climate, wood-burning or gas fireplace.
5. Tumor: insidious onset, gradual +/- neurological deficits.

8. Differential Diagnosis
6. Intracranial bleeding: anticoagulants + no history of trauma
Or a normal patient with history of trauma.
7. Hypertensive emergency: very high BP (> 180/120) + end organ
damage like intracranial bleeding, stroke..
8. Tension headache: band like + dull + no systemic associated
symptoms + does not increase with activity
9. Migraine: unilateral + pulsating or throbbing + increases with
activity + associated symptoms (nausea , vomiting, photophobia,
phonophobia) and maybe an aura.
10. Cluster headache: young patient + unilateral + tearing and injection
of the eye on the effected side

9. Work up
• CBC: to check for coagulopathy.
• Non contrast CT to diagnose subarachnoid hemorrhage,
intracranial hemorrhage, masses or stroke.
• CT scan is not needed if there are no red flags especially
if the patient has history of the same headache like in
migraines.
• LP: if you suspect subarachnoid hemorrhage but CT is
normal.
Ø Xanthochromia

10. Headache in pediatrics age group
• Most cases is benign
• Red flags: same as adults, but be especially aware of vomiting.
• Vomiting that’s been going on for a while can point towards the
possibility of having a mass.
• GI vomiting vs projectile vomiting
• Due to increased ICP, nausea, happens mostly in the morning or as
soon as the patient wakes up.
• Consult a neurologist/neurosurgeon in the patient needs admission.

11. References
• Up-to-date
• EM basic