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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.

Table 159-1 Etiology of Headache


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 roots.2

Approach to 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. 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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