First 5 minutes for critical headache
›Time critical workflow
›Monitor
›Continuous pulse oximetry
›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 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