Headache accounts for up to 4% of all ED visits. In
the U.S., this represents around 5 million visits each year.1–3 Migraine
headaches have prevalence rates of approximately 17% in
women and 5% in men. Most ED patients have benign primary
headache syndromes, but approximately 3.8% have serious
or secondary pathology.1
For practical purposes, headaches generally are divided into primary headache
syndromes, including migraine, tension-type, and cluster
headaches, and secondary headache causes. Emergency
physicians generally are focused on identifying those patients whose
headaches are caused by life-threatening conditions. The most common
causes are listed in Table 159-1.
159-1 Etiology of Headache
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159-1 Etiology of Headache
|Critical Secondary Causes||Reversible Secondary Causes|
|Vascular conditions||Non–central nervous system infections|
|Cavernous/venous sinus thrombosis||Drug-related causes|
|Arteriovenous malformation||Long-term analgesic use (medication
|Carotid or vertebral artery dissection||Monosodium glutamate|
|Central nervous system infection||Miscellaneous causes|
|Cerebral abscess||Primary Headache Syndromes|
|Nitrates and nitrites|
|Monoamine oxidase inhibitors|
|Carbon monoxide poisoning|
|High-altitude cerebral edema|
The brain parenchyma is largely insensible to pain. Pain may
originate from large cranial vessels, proximal intracranial vessels,
and the dura mater. Anterior vessels are innervated by branches
of the ophthalmic division of the trigeminal nerve, whereas contents
of the posterior fossa are innervated by branches of the C2 nerve
Patients with Headache in the ED
The 1996 American College of Emergency Physicians (ACEP) Clinical Policy
for Adults with Headache groups all causes of headache into four broad
categories3 (Table 159-2).
Evaluation of the headache patient has four essential objectives:
1. To appropriately select patients for emergency investigation
and treatment of suspected critical secondary headache causes
2. To diagnose and effectively treat patients with generally benign
and reversible secondary headache causes
3. To provide effective treatment for primary headache syndromes
4. To provide appropriate disposition and follow-up (including outpatient investigations
and referral as necessary) for all discharged patients
Table 159-2 American
College of Emergency Physicians Headache Categories
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