Cardiac monitoring if severe hypertension or altered status
IV access criteria
At least 1 large bore IV if red flags present
2 IV lines if shock or impending airway concern
Immediate tests
Point of care glucose if altered mental status
Noncontrast CT head immediately if new focal deficit or thunderclap
Immediate treatments when indicated
Treat severe nausea and vomiting to enable exam and imaging
Early antibiotics and dexamethasone if suspected bacterial meningitis after blood cultures when feasible
Diagnostic sequencing
Diagnostic pathway
Primary headache phenotype with normal neuro exam
No routine imaging if typical recurrent pattern and no red flags
Treat and reassess response
Thunderclap or SAH concern
Noncontrast CT head
If nondiagnostic and high suspicion persists
CT angiography head and neck option
Lumbar puncture option when appropriate
Fever or meningismus
Blood cultures
Empiric antimicrobials if high suspicion
CT head before LP if focal deficit or altered mental status or papilledema
Papilledema or raised intracranial pressure concern
Neuroimaging prior to LP
MRV or CTV if venous thrombosis concern
Suspected temporal arteritis
ESR and CRP
Steroid initiation if vision symptoms
Symptom control and specific therapies
Acute migraine treatment examples
Fluids
Normal saline IV bolus 500 mL to 1000 mL if dehydration or vomiting
Reassess volume status after bolus
NSAID option
Ketorolac IV 15 mg
Maximum single dose 30 mg local protocol dependent
Acetaminophen option
Acetaminophen PO 1000 mg
Daily maximum dose consideration with liver disease
Dopamine antagonist antiemetic options
Metoclopramide IV 10 mg
Prochlorperazine IV 10 mg
Akathisia prophylaxis option
Diphenhydramine IV 25 mg
Sedation risk counseling
Magnesium option for migraine
Magnesium sulfate IV 1 g
Repeat dose 1 g if partial response
Recurrence prevention option
Dexamethasone IV 10 mg
Hyperglycemia risk consideration
Opioids avoidance
Medication overuse risk
Increased return visit risk
Cluster headache acute treatment
High flow oxygen
Nonrebreather 12 L per minute
Up to 15 L per minute if needed
Triptan option
Sumatriptan SC 6 mg
Contraindications in vascular disease
Suspected temporal arteritis with vision symptoms
Steroid examples local protocol dependent
Prednisone PO 60 mg daily
IV methylprednisolone option for acute vision loss pathway
Specialist pathway
Ophthalmology urgent evaluation
Rheumatology follow up planning
Suspected acute angle closure glaucoma
Emergent ophthalmology pathway
Time critical vision risk
Avoid delaying therapy for imaging if classic presentation
Reassessment loop
Reassessment cadence
Repeat vitals after therapy
Repeat neuro exam after symptom improvement
New deficits trigger immediate imaging pathway
Persistent severe pain despite standard therapy triggers expanded secondary headache evaluation
Disposition
ICU and inpatient criteria
Higher level of care triggers
Intracranial hemorrhage on imaging
Subarachnoid hemorrhage confirmed or strongly suspected
Meningitis or encephalitis concern requiring IV therapy
Acute stroke syndrome
Hypertensive emergency with end organ features
Persistent altered mental status
Refractory vomiting with inability to maintain hydration
Observation criteria
ED observation pathway candidates
Uncertain diagnosis after initial negative workup with persistent symptoms
Need for serial neuro exams
Need for serial blood pressure management and reassessment
Need for repeat analgesic therapy and hydration
Discharge criteria
Safe discharge features
Normal neurologic exam
No red flags after evaluation
Pain controlled to functional baseline or acceptable level
Tolerating oral intake
Reliable follow up plan
Clear return precautions understood
Discharge Instructions
Copy discharge instructions
Patient facing instructions
Headache evaluation today did not show a dangerous cause based on your exam and tests performed
Return immediately for sudden severe headache maximal at onset
Return immediately for weakness numbness trouble speaking vision loss or confusion
Return immediately for fever with stiff neck or new rash
Return immediately for persistent vomiting or inability to drink fluids
Avoid taking pain medicines more than a few days per week to reduce rebound headaches
Use your prescribed rescue plan as directed
Follow up with primary care within 2 to 7 days
Neurology follow up within 2 to 4 weeks for recurrent or disabling headaches
If pregnant or postpartum return urgently for severe headache with vision changes swelling shortness of breath or upper abdominal pain
References
Guidelines and key sources
Reference set
American College of Emergency Physicians clinical policy for acute headache and suspected subarachnoid hemorrhage 2019
American Heart Association and American Stroke Association guideline for aneurysmal subarachnoid hemorrhage 2023
American Headache Society evidence assessment of parenteral pharmacotherapies for acute migraine in the emergency department 2016
European League Against Rheumatism recommendations for large vessel vasculitis including giant cell arteritis 2018
Infectious Diseases Society of America guideline for bacterial meningitis 2004
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.