Acute Headache

A sudden severe headache, particularly a thunderclap presentation, should trigger assessment for subarachnoid hemorrhage and other secondary causes. Aneurysmal subarachnoid hemorrhage is an emergency and commonly presents with sudden severe headache accompanied by nausea, vomiting, or photophobia. BMJBMJSubarachnoid hemorrhage - Symptoms, diagnosis and treatment | BMJ Best Practice US

Use a structured red-flag screen and focused examination rather than response to treatment to determine residual risk. SNOOP and SNNOOP10 frameworks are intended to support screening for secondary headache and ED referral, and sudden onset plus an abnormal neurologic examination have greater predictive value for secondary headache than many other red flags. Wiley+2WileyThe Diagnostic Evaluation of Secondary Headache DisordersWileyClinic and Emergency Room Evaluation and Testing of ...WileyHeadache diagnosis and treatment: A pilot knowledge and ...

A normal or improving pain score after treatment does not exclude serious intracranial disease. ACEP policy states that response to therapy should not be used as the sole diagnostic indicator of headache etiology. ScienceDirectScienceDirectClinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache - ScienceDirect

Nontraumatic subarachnoid hemorrhage is most often due to rupture of an intracranial aneurysm and carries substantial morbidity and mortality. The abrupt rise in intracranial pressure and toxic effects of subarachnoid blood contribute to its acute complications. BMJBMJSubarachnoid hemorrhage - Symptoms, diagnosis and treatment | BMJ Best Practice US

When CT is nondiagnostic and clinical suspicion remains high, lumbar puncture is a recommended second-line test in a CT/LP approach. JAMAJAMAShifts in Diagnostic Testing for Headache in the ... A separate guideline review concludes that CT/LP and noncontrast CT followed by CTA are both reasonable diagnostic strategies, but notes insufficient evidence to establish a clearly preferred approach. ScienceDirectScienceDirectClinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

The practical implication is to make the post-CT plan explicit before discharge: resolve whether residual concern warrants CSF testing, vascular imaging, observation, or specialist input. Do not infer exclusion of subarachnoid hemorrhage solely from symptom improvement after migraine-directed therapy. JAMA+2JAMAShifts in Diagnostic Testing for Headache in the ...ScienceDirectClinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache - ScienceDirectScienceDirectClinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

For acute migraine, evidence-supported first-line oral analgesics include NSAIDs, with the strongest evidence cited for aspirin, ibuprofen, and diclofenac potassium. Paracetamol is less effective and is best reserved for patients unable to take NSAIDs. NatureNatureDiagnosis and management of migraine in ten steps For moderate or severe attacks, triptans are established acute therapy; newer effective acute options include CGRP receptor antagonists and lasmiditan. NatureNatureMigraine | Nature Reviews Disease Primers

Nausea or vomiting can justify a prokinetic antiemetic adjunct such as metoclopramide. NatureNatureDiagnosis and management of migraine in ten steps A reported ED regimen for established severe migraine is subcutaneous sumatriptan 6 mg with metoclopramide or prochlorperazine. BMJBMJHeadache management: pharmacological approaches | Practical Neurology The supplied sources do not provide enough U.S.-labeling detail to specify broader triptan contraindications, dosing limits, or gepant and lasmiditan dosing; verify current labeling before prescribing.

Avoid opioids and barbiturates for migraine when possible. Their efficacy is uncertain or limited, and they are associated with adverse effects, dependency risk, repeat ED use, tolerance, and addiction. BMJ+1BMJa review of the evidence and consensus recommendationsNatureDiagnosis and management of migraine in ten steps Treatment choices should also account for medication-overuse headache: overuse is defined as use on at least 10 days per month for triptans, opioids, codeine, or ergotamine, or at least 15 days per month for simple analgesics such as NSAIDs or paracetamol. BMJBMJMigraine-advanced preventative treatments: the British Association for the Study of Headache Clinical Practice Recommendations and Consensus Guidance | Journal of Neurology, Neurosurgery & Psychiatry

For severe or refractory headache requiring inpatient parenteral management, reported medication classes include dihydroergotamine, NSAIDs, antiemetics, antiepileptics, magnesium, corticosteroids, lidocaine, and ketamine; selection should be tailored to the individual headache disorder and patient. BMJBMJa review of the evidence and consensus recommendations Admission goals should include confirming the diagnosis and addressing factors that sustain the headache presentation. BMJBMJa review of the evidence and consensus recommendations

Peripheral cranial nerve blocks may be useful in selected acute headache presentations and can reduce reliance on opioid-based therapy. They require procedural consent and attention to bleeding, infection, pain at the injection site, prior cranial surgery, and implanted devices such as shunts or nerve stimulators. BMJBMJPeripheral nerve blocks for headache disorders | Practical Neurology

Avoid routine steroid-containing repeat peripheral nerve blocks in patients already receiving corticosteroids; systemic steroid effects are clinically meaningful, and the cited source advises avoiding repeat steroid-containing blocks within 3 months or longer in such patients. BMJBMJPeripheral nerve blocks for headache disorders | Practical Neurology

A headache diary can help monitor response to treatment and identify patterns relevant to ongoing management. BMJBMJAcute treatment of migraine in children and adolescents For recurrent migraine, document acute-treatment days rather than only total doses, because medication overuse thresholds are defined by days of use per month. BMJBMJMigraine-advanced preventative treatments: the British Association for the Study of Headache Clinical Practice Recommendations and Consensus Guidance | Journal of Neurology, Neurosurgery & Psychiatry

Arrange reassessment when headache pattern changes, new red flags develop, neurologic findings emerge, or acute-treatment needs approach medication-overuse levels. SNNOOP10-type red-flag screening provides a structured basis for re-triage. BMJ+1BMJMigraine-advanced preventative treatments: the British Association for the Study of Headache Clinical Practice Recommendations and Consensus Guidance | Journal of Neurology, Neurosurgery & PsychiatryWileyHeadache diagnosis and treatment: A pilot knowledge and ...