Headache Emergencies

  • Deena M. NasrEmail author
  • Sherri A. Braksick


Headache is a common complaint in the emergency department. Although the most common causes of headaches are benign, the differential diagnosis is vast and can include potentially catastrophic neurologic etiologies. It is important to identify those with high risk of having a secondary headache in order to expedite further workup and management thereby reducing the risk of morbidity and mortality.

The most important information regarding a headache comes from the patient’s history and physical examination. History alone can help you discern if it is most likely a primary benign headache or concerning secondary headache syndrome. Most emergencies presenting with headaches can be ruled out with a CT of the head and/or a lumbar puncture with CSF investigations. However, a thorough history and examination will aid in forming a differential diagnosis and help fine-tune ongoing investigations and treatment.


Thunderclap headache Intracranial hemorrhage Cerebral venous thrombosis Cervical arterial dissection Colloid cyst Meningoencephalitis Brain tumor Cerebral vasoconstriction Pituitary apoplexy Cluster headache Migraine 


  1. 1.
    Goldstein JN, Camargo CAJ, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684–90.CrossRefGoogle Scholar
  2. 2.
    Lucado J, Paez K, Elixhauser A. Headaches in U.S. hospitals and emergency departments, 2008: statistical brief #111. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville; 2006.Google Scholar
  3. 3.
    Devenney E, Neale H, Forbes RB. A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based? J Headache Pain . [Research Support, Non-US Gov’t Review]. 2014;15:49.CrossRefGoogle Scholar
  4. 4.
    Wijdicks EF, Kerkhoff H, van Gijn J. Long-term follow-up of 71 patients with thunderclap headache mimicking subarachnoid haemorrhage. Lancet. 1988;2(8602):68–70.CrossRefGoogle Scholar
  5. 5.
    Landtblom AM, Fridriksson S, Boivie J, Hillman J, Johansson G, Johansson I. Sudden onset headache: a prospective study of features, incidence and causes. Cephalalgia. [Research Support, Non-U.S. Gov’t]. 2002;22(5):354–60.CrossRefGoogle Scholar
  6. 6.
    Linn FH, Wijdicks EF, van der Graaf Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet. [Research Support, Non-U.S. Gov’t]. 1994;344(8922):590–3.CrossRefGoogle Scholar
  7. 7.
    Ducros A, Bousser MG. Thunderclap headache. BMJ. [Review]. 2013;346:e8557.CrossRefGoogle Scholar
  8. 8.
    Katz BS, Fugate JE, Ameriso SF, Pujol-Lereis VA, Mandrekar J, Flemming KD, et al. Clinical worsening in reversible cerebral vasoconstriction syndrome. JAMA Neurol. [Case Reports Multicenter Study]. 2014;71(1):68–73.CrossRefGoogle Scholar
  9. 9.
    Suchdev K, Norris G, Zak I, Mohamed W, Ibrahim M. Fulminant reversible cerebral vasoconstriction syndrome. Neurohospitalist. 2018;8(1):NP5–8.CrossRefGoogle Scholar
  10. 10.
    Fugate JE, Ameriso SF, Ortiz G, Schottlaender LV, Wijdicks EF, Flemming KD, et al. Variable presentations of postpartum angiopathy. Stroke. 2012;43(3):670–6.CrossRefGoogle Scholar
  11. 11.
    Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome: clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol. 2015;14(9):914–25. Epub 2015 Jul 13CrossRefGoogle Scholar
  12. 12.
    Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P, Long PH, Noorollah LD, Panagos PD, Schievink WI, Schwartz NE, Shuaib A, Thaler DE, Tirschwell DL, American Heart Association Stroke Council. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155–74. Epub 2014 Aug 7CrossRefGoogle Scholar
  13. 13.
    Markus HS, Levi C, King A, Madigan J, Norris J, Cervical Artery Dissection in Stroke Study (CADISS) Investigators. Antiplatelet therapy vs anticoagulation therapy in cervical artery dissection: the Cervical Artery Dissection in Stroke Study (CADISS) Randomized Clinical Trial Final Results. JAMA Neurol. 2019;76:657–64.CrossRefGoogle Scholar
  14. 14.
    Narvid J, Amans MR, Cooke DL, Hetts SW, Dillon WP, Higashida RT, et al. Spontaneous retroclival hematoma: a case series. J Neurosurg. [Case Reports]. 2016;124(3):716–9.CrossRefGoogle Scholar
  15. 15.
    Wolf ME, Szabo K, Griebe M, Forster A, Gass A, Hennerici MG, et al. Clinical and MRI characteristics of acute migrainous infarction. Neurology. 2011;76(22):1911–7.CrossRefGoogle Scholar
  16. 16.
    Mitsias P, Ramadan NM. Headache in ischemic cerebrovascular disease. Part I: clinical features. Cephalalgia. [Review]. 1992;12(5):269–74.CrossRefGoogle Scholar
  17. 17.
    Weingarten S, Kleinman M, Elperin L, Larson EB. The effectiveness of cerebral imaging in the diagnosis of chronic headache. Arch Intern Med. 1992;152(12):2457–62.CrossRefGoogle Scholar
  18. 18.
    Black DF, Bartleson JD, Bell ML, Lachance DH. SMART: stroke-like migraine attacks after radiation therapy. Cephalalgia. [Case Reports]. 2006;26(9):1137–42.CrossRefGoogle Scholar
  19. 19.
    Zheng Q, Yang L, Tan LM, Qin LX, Wang CY, Zhang HN. Stroke-like migraine attacks after radiation therapy syndrome. Chin Med J (Engl). [Review]. 2015;128(15):2097–101.CrossRefGoogle Scholar
  20. 20.
    Black DF, Morris JM, Lindell EP, Krecke KN, Worrell GA, Bartleson JD, et al. Stroke-like migraine attacks after radiation therapy (SMART) syndrome is not always completely reversible: a case series. AJNR Am J Neuroradiol. [Case Reports]. 2013;34(12):2298–303.CrossRefGoogle Scholar
  21. 21.
    The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.CrossRefGoogle Scholar
  22. 22.
    Artto V, Nissila M, Wessman M, Palotie A, Farkkila M, Kallela M. Treatment of hemiplegic migraine with triptans. Eur J Neurol. [Evaluation Studies Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t]. 2007;14(9):1053–6.CrossRefGoogle Scholar
  23. 23.
    Hakan T, Ceran N, Erdem I, Berkman MZ, Goktas P. Bacterial brain abscesses: an evaluation of 96 cases. J Infect. 2006;52(5):359–66.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of NeurologyMayo ClinicRochesterUSA

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