Evaluation and Management of Life-Threatening Headaches
Table of Contents

<<Webinar: Life-Threatening Headaches Can't-Miss Causes & COVID-19 Connections, Table of Contents

Evaluation and Management of Life-Threatening Headaches in the Emergency Department (Stroke CME and Pharmacology CME) Excerpt

Though patients often present to the ED seeking relief from headaches that cause significant pain and suffering, 90% of them can be considered “benign.” It is essential to identify the 10% of headache patients who are in danger of having a life-threatening disorder presenting with a sudden and severe headache to ensure that they are treated quickly and effectively.

What are the red flags for recognizing that a headache is potentially life-threatening?

What are the most common causes of life-threatening headaches? (Subarachnoid hemorrhage, cervical artery dissection, central venous thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome.)

What are the signs and symptoms of these headaches?

When your patient describes his headache, what are the six descriptors that are most concerning?

What are the high-yield laboratory tests?

When SAH is suspected, when is CT required? When is it not?

When is neuroimaging required prior to performing a lumbar puncture?

When is IV antihypertensive medication called for? Which drugs and what dosage?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
    1. Subarachnoid Hemorrhage
    2. Cervical Artery Dissection
    3. Cerebral Venous Thrombosis
    4. Idiopathic Intracranial Hypertension
    5. Giant Cell Arteritis
    6. Posterior Reversible Encephalopathy Syndrome
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Vital Signs
      2. Neurologic Function
      3. Cranial Nerves
      4. Head and Neck Examination
      5. Fundoscopic Examination
  9. Diagnostic Studies
    1. Laboratory Testing
    2. Radiographic Imaging
      1. Level B Recommendations (Moderate Strength of Evidence)
      2. Level C Recommendations (Weak Strength of Evidence)
      3. Computed Tomography and Subarachnoid Hemorrhage
    3. Lumbar Puncture
    4. Ocular Ultrasonography
  10. Treatment
    1. Subarachnoid Hemorrhage
    2. Cerebral Venous Thrombosis
    3. Idiopathic Intracranial Hypertension
    4. Posterior Reversible Encephalopathy Syndrome
    5. Cervical Artery Dissection
    6. Acute Angle Closure Glaucoma
    7. Giant Cell Arteritis
    8. Pre-Eclampsia
  11. Controversies and Cutting Edge
  12. Disposition
  13. Summary
  14. Risk Management Pitfalls for Emergency Department Management of Severe, Sudden Onset Headache
  15. Time- And Cost-Effective Strategies
  16. Case Conclusions
  17. Clinical Pathway for Emergency Department Management of Subarachnoid Hemorrhage
  18. Tables and Figures
    1. Table 1. Life-Threatening Secondary Causes of Headache
    2. Table 2. Historical and Physical Examination Findings Associated with Subarachnoid Hemorrhage
    3. Table 3. Red Flags for Life-Threatening Headaches
    4. Table 4. Historical Factors and Concerning Descriptors
    5. Table 5. Stepwise Approach to the Fundoscopic Examination
    6. Table 6. Intravenous Antihypertensive Medications for Treating Hypertensive Emergencies
    7. Table 7. Ottawa Subarachnoid Hemorrhage Rule
    8. Table 8. Modified Dandy Criteria for Diagnosing Idiopathic Intracranial Hypertension
    9. Table 9. Medications for Treatment of Acute Angle Closure Glaucoma
    10. Table 10. Criteria for the Diagnosis of Pre Eclampsia (>= 20 Weeks' Gestation)
    11. Figure 1. Ocular Ultrasound Evaluating Elevated Intracranial Pressure
  19. References


Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition.

Case Presentations

A previously healthy 30-year-old man presents to the ED complaining of the “worst headache of my life.” He describes it as sharp, nonradiating, with an abrupt onset 5 hours ago. You are concerned for subarachnoid hemorrhage. You provide pain medication and obtain a noncontrast CT scan of the head, which is negative. The patient is feeling better and wants to go home. You wonder whether a negative CT is sufficient to rule out an SAH or whether a lumbar puncture should be done...

A 55-year-old man with history of nonsmall cell lung cancer who is on cisplatin presents with an acute headache and lethargy for 6 hours. His vital signs are remarkable for a blood pressure of 210/120 mm Hg, heart rate of 70 beats/min, and a temperature of 36.7°C (98°F). His physical exam reveals a lethargic patient with no localizing neurologic signs and no meningismus. You order a noncontrast CT of the head and consider lowering this patient’s blood pressure, though you wonder how much and how fast it should be reduced...

A 45-year-old woman presents to the ED complaining of a severe occipital headache, neck pain, and dizziness. Earlier in the day, she was involved in a motor vehicle crash and suffered “whiplash.” Her neurologic exam is normal, including no nystagmus and normal cerebellar function, but you are concerned that this patient may have a vertebral artery dissection, and you order a CTA head and neck. You wonder: if it’s positive, should the treatment include anticoagulation or antiplatelet therapy...or both?


The third edition of the International Classification of Headache Disorders (ICHD-3), published in January 2018, is the most up-to-date and widely accepted standard criteria for the classification of headaches.1 The ICHD-3 classifies headaches into 3 distinct categories: (1) primary headache disorders, including migraine, tension, and cluster headaches; (2) secondary headaches, including potentially life-threatening forms of headaches such as those secondary to vascular disorders, traumatic injury, and disorders in hemostasis; and (3) cranial neuropathies, such as trigeminal neuralgia.

The National Hospital Ambulatory Medical Care Survey reviewed over 10,000 patients presenting to emergency departments (EDs) for acute headache and found that 2% represented secondary headaches.2 Although they are rare, life-threatening headaches require prompt diagnosis and treatment, as delays in some diagnoses can have a mortality rate approaching 50%.3

Evaluating complaints of acute headache is a common practice in the ED, and distinguishing benign from serious pathology can be a diagnostic challenge. A focused workup begins with a careful, well-organized clinical history and physical examination. Physical examination findings such as abnormal vital signs, papilledema, cranial nerve palsies, and neck pain are suggestive of more concerning headache etiologies.4 Resources such as ocular ultrasound, neuroimaging, and lumbar puncture are important strategies, but the sensitivity and specificity of the results must be understood in order to apply them correctly. This issue of Emergency Medicine Practice focuses on the most commonly encountered causes of life-threatening secondary headaches and provides best-practice recommendations on their initial evaluation and management.

Critical Appraisal of the Literature

A literature search from 1993 to 2018 was conducted using PubMed and Ovid MEDLINE®, with the search terms headaches AND emergency, sudden onset, fever, visual symptoms, neurologic deficits, high-risk, trauma, immunocompromised, pregnancy, coagulopathy, and life threatening. The National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews were searched. Guidelines published by the American College of Emergency Physicians (ACEP) and the American Academy of Neurology were searched. International guidelines, including the Canadian and European neurology guidelines, were also reviewed. Over 500 abstracts published within the last 25 years were examined, and 89 of these full-text articles were reviewed and included for reference. Many of the identified articles were prospective studies, meta-analyses, clinical guidelines, and literature reviews.

Risk Management Pitfalls for Emergency Department Management of Severe, Sudden Onset Headache

4. “The 55-year-old patient I evaluated for a new-type headache had no neurologic deficits, so I suspected that the etiology was benign, and I did not obtain imaging.”

ACEP Clinical Policy recommends that patients aged > 50 years who present with a new type of headache and a normal neurologic examination should be considered for an urgent neuroimaging study (Level C recommendation).

5. “She was 7 days post partum and came in complaining of new-onset headache and with a blood pressure of 186/92 mm Hg. Her urinalysis was negative for protein, so I ruled out pre-eclampsia.”

ACOG recommends that diagnosis of severe pre-eclampsia includes new headache and hypertension. Proteinuria is no longer necessary to diagnose pre-eclampsia if other symptoms are present. Postpartum pre-eclampsia and eclampsia may occur up to 4 weeks post partum. Treatment with IV magnesium and antihypertensives is indicated for this patient.

6. “My 60-year-old patient presented with signs of an anterior stroke; however, her last known well time was 12 hours ago, so I did not consult neurosurgery, since she was out of the window for thrombolytics.”

The 2018 AHA Guidelines for endovascular therapy in acute ischemic stroke recommends that, in select patients with signs of acute stroke whose onset is within 6 to 24 hours, mechanical thrombectomy is reasonable (Level IIa recommendation).

Tables and Figures

Life-Threatening Secondary Causes of Headache
Life-Threatening Secondary Causes of Headache


Historical and Physical Examination Findings Associated with Subarachnoid Hemorrhage



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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