{
  "schemaVersion": 2,
  "eyebrow": "Emergency Medicine",
  "title": "Acute Headache",
  "summary": "Acute headache evaluation hinges on recognizing secondary causes before treating presumed primary headache. Sudden onset and abnormal neurologic examination are especially predictive red flags; persistent concern for subarachnoid hemorrhage after nondiagnostic CT warrants further evaluation, commonly lumbar puncture.",
  "seoDescription": "Point-of-care evaluation of acute headache, emphasizing red flags, subarachnoid hemorrhage testing, diagnostic limits, and evidence-based treatment of primary headache.",
  "clinicalQuestion": "How should clinicians identify dangerous secondary causes and safely treat acute primary headache presentations?",
  "specialty": "Emergency Medicine and Neurology",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "acute headache",
    "thunderclap headache",
    "secondary headache",
    "subarachnoid hemorrhage",
    "migraine",
    "cluster headache",
    "emergency department"
  ],
  "keyTakeaways": [
    "Do not use improvement after analgesia or antiemetics as the sole indicator that acute headache is benign or primary. [15]",
    "Sudden-onset headache and an abnormal neurologic examination are among the red flags most predictive of secondary headache. [18]",
    "For suspected subarachnoid hemorrhage with nondiagnostic CT and continuing clinical concern, lumbar puncture remains a recommended second-line test; CT/LP and noncontrast CT/CTA are both described as reasonable strategies, with residual uncertainty about the preferred pathway. [1][16]",
    "Avoid opioids for acute migraine when alternatives are available because of limited effectiveness and associations with repeat ED visits and long-term tolerance, dependence, and addiction. [3][11]",
    "When a severe migraine diagnosis is secure, prompt migraine-directed treatment can facilitate ED discharge; subcutaneous sumatriptan 6 mg with an antiemetic is one reported ED approach. [2]"
  ],
  "sections": [
    {
      "id": "initial-risk-stratification",
      "eyebrow": "First Decision",
      "heading": "Separate secondary headache from a primary headache syndrome",
      "intro": "The diagnostic priority is not pain intensity but whether the presentation could reflect an immediately dangerous secondary cause.",
      "paragraphs": [
        "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. [10]",
        "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. [18][19][20]",
        "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. [15]"
      ],
      "bullets": [
        "Escalate investigation for abrupt maximal-at-onset headache, focal neurologic findings, altered mental status, or other secondary-headache red flags. [18][19][20]",
        "Reassess the neurologic examination after initial symptom treatment; clinical improvement should not terminate evaluation when the pretest concern remains substantial. [15]",
        "Document onset pattern, time from onset, prior headache phenotype, neurologic findings, systemic features, and the rationale for either emergency testing or outpatient management. SNNOOP10-type red-flag frameworks support this approach. [19][20]"
      ],
      "subsections": [],
      "table": {
        "caption": "High-yield features that should shift acute headache evaluation toward secondary causes. [18][19][20]",
        "columns": [
          "Clinical feature",
          "Decision implication"
        ],
        "rows": [
          [
            "Sudden-onset or thunderclap headache",
            "Prioritize evaluation for subarachnoid hemorrhage and other secondary causes; sudden onset is a more predictive red flag. [10][18]"
          ],
          [
            "Abnormal neurologic examination",
            "Treat as a higher-risk feature for secondary headache and pursue cause-directed evaluation. [18]"
          ],
          [
            "Systemic symptoms or signs, altered pattern, or other SNNOOP10 features",
            "Use the complete clinical context to determine urgency of imaging, laboratory testing, consultation, or referral. [19][20]"
          ],
          [
            "Pain relief after ED therapy",
            "Do not regard relief as proof of a primary headache diagnosis. [15]"
          ]
        ]
      }
    },
    {
      "id": "thunderclap-headache",
      "eyebrow": "Diagnostic Pathway",
      "heading": "Evaluate suspected subarachnoid hemorrhage when clinical concern persists",
      "intro": "Testing should be directed by the presentation and residual suspicion, not by the availability of a single reassuring result.",
      "paragraphs": [
        "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. [10]",
        "When CT is nondiagnostic and clinical suspicion remains high, lumbar puncture is a recommended second-line test in a CT/LP approach. [1] 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. [16]",
        "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. [1][15][16]"
      ],
      "bullets": [
        "For an acute thunderclap presentation, obtain urgent head CT as part of the emergency evaluation for subarachnoid hemorrhage. [10][16]",
        "After nondiagnostic CT with persistent concern, use CT/LP or CT/CTA according to local pathway, patient factors, and shared decision-making about downstream testing; the supplied evidence does not establish one universal preferred pathway. [1][16]",
        "If subarachnoid hemorrhage is identified or strongly suspected, treat as an emergency requiring definitive acute-care management and specialty involvement. [10]"
      ],
      "subsections": [],
      "table": {
        "caption": "Testing options after a nondiagnostic CT in suspected subarachnoid hemorrhage. [1][16]",
        "columns": [
          "Scenario",
          "Next diagnostic consideration",
          "Evidence limitation"
        ],
        "rows": [
          [
            "Clinical concern resolves after CT and reassessment",
            "Disposition depends on the full clinical assessment and local protocol; pain response alone is insufficient to determine etiology. [15]",
            "The supplied sources do not provide a validated universal discharge threshold. [15][16]"
          ],
          [
            "CT nondiagnostic with persistent concern for subarachnoid hemorrhage",
            "Lumbar puncture is a recommended second-line test in the CT/LP pathway. [1]",
            "Testing sequence should be individualized to clinical context. [1][16]"
          ],
          [
            "Considering vascular imaging after noncontrast CT",
            "Noncontrast CT/CTA is described as a reasonable alternative strategy. [16]",
            "Available evidence does not clearly establish superiority over CT/LP. [16]"
          ]
        ]
      }
    },
    {
      "id": "primary-headache-treatment",
      "eyebrow": "Treatment",
      "heading": "Treat a confirmed primary headache phenotype without masking diagnostic uncertainty",
      "intro": "Primary headache therapy is appropriate once the phenotype is established and dangerous secondary causes have been reasonably addressed.",
      "paragraphs": [
        "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. [11] For moderate or severe attacks, triptans are established acute therapy; newer effective acute options include CGRP receptor antagonists and lasmiditan. [12]",
        "Nausea or vomiting can justify a prokinetic antiemetic adjunct such as metoclopramide. [11] A reported ED regimen for established severe migraine is subcutaneous sumatriptan 6 mg with metoclopramide or prochlorperazine. [2] 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. [3][11] 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. [8]"
      ],
      "bullets": [
        "Use NSAIDs as first-line acute therapy for many migraine attacks when not contraindicated; aspirin, ibuprofen, and diclofenac potassium have the strongest cited evidence. [11]",
        "Add metoclopramide when nausea, vomiting, or impaired gastric emptying is clinically important. [11]",
        "For established severe migraine in the ED, subcutaneous sumatriptan 6 mg plus an antiemetic is a reported approach. [2]",
        "Screen acute-medication frequency at every recurrent-headache encounter to identify medication overuse and guide preventive planning. [8]",
        "Avoid opioids as routine acute migraine therapy. [3][11]"
      ],
      "subsections": [
        {
          "heading": "Cluster headache",
          "paragraphs": [
            "When the clinical syndrome is cluster headache, treatment differs materially from migraine. Evidence-based acute options include subcutaneous sumatriptan, intranasal sumatriptan or zolmitriptan, and high-flow oxygen via a non-rebreather mask; noninvasive vagus nerve stimulation is cited for episodic cluster headache. [6]"
          ],
          "bullets": [
            "Subcutaneous sumatriptan, high-flow oxygen, and noninvasive vagus nerve stimulation have randomized trial evidence for stopping attacks within 15 minutes; intranasal sumatriptan and zolmitriptan showed benefit within 30 minutes. [6]",
            "Lithium is generally used as a second-line option, more often for chronic than episodic cluster headache; it requires regular serum monitoring because of a narrow therapeutic index, with a cited target serum concentration of 0.4-1.2 mEq/L. [6]"
          ]
        }
      ],
      "table": {
        "caption": "Phenotype-directed acute treatment options supported in the supplied literature. [2][6][11][12]",
        "columns": [
          "Headache phenotype",
          "Treatment option",
          "Important clinical consideration"
        ],
        "rows": [
          [
            "Migraine, mild to moderate",
            "NSAID; strongest cited evidence for aspirin, ibuprofen, and diclofenac potassium. [11]",
            "Paracetamol has lower efficacy and is an option when NSAIDs are not tolerated. [11]"
          ],
          [
            "Migraine with nausea or vomiting",
            "Metoclopramide as a prokinetic antiemetic adjunct. [11]",
            "Use as adjunctive therapy rather than as a substitute for reassessing a possible secondary cause. [11][15]"
          ],
          [
            "Established severe migraine in the ED",
            "Subcutaneous sumatriptan 6 mg with metoclopramide or prochlorperazine. [2]",
            "Do not use treatment response alone to establish benign etiology. [15]"
          ],
          [
            "Cluster headache",
            "Subcutaneous or intranasal sumatriptan, intranasal zolmitriptan, or high-flow oxygen by non-rebreather mask. [6]",
            "Select for rapid attack termination and account for attack frequency and practicality of oxygen access. [6]"
          ]
        ]
      }
    },
    {
      "id": "refractory-and-procedural-options",
      "eyebrow": "Escalation",
      "heading": "Use refractory-headache interventions selectively",
      "intro": "Escalation should include diagnostic reconsideration, not simply additional analgesic classes.",
      "paragraphs": [
        "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. [3] Admission goals should include confirming the diagnosis and addressing factors that sustain the headache presentation. [3]",
        "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. [9]",
        "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. [9]"
      ],
      "bullets": [
        "Before escalating parenteral therapy, reconsider secondary headache, medication overuse, and the accuracy of the working phenotype. [3][8]",
        "Avoid opioids during refractory-care pathways when alternatives are available. [3]",
        "Do not perform peripheral nerve blocks at prior surgical sites such as burr holes or craniotomy sites because of concern for anesthetic infiltration into the central nervous system. [9]",
        "Use special caution or avoid blocks in patients with implanted shunts or nerve stimulators unless performed by appropriately skilled clinicians with explicit consent. [9]"
      ],
      "subsections": [],
      "table": {
        "caption": "Safety considerations for peripheral nerve blocks in headache care. [9]",
        "columns": [
          "Consideration",
          "Clinical action"
        ],
        "rows": [
          [
            "Consent",
            "Discuss procedural pain, bleeding, infection, and other site-specific complications before injection. [9]"
          ],
          [
            "Prior cranial surgical site",
            "Avoid routine injection at prior burr-hole or craniotomy sites because of risk of central nervous system anesthetic infiltration. [9]"
          ],
          [
            "Implanted shunt or nerve stimulator",
            "Routinely avoid blocks; exceptional use requires skilled operators and informed consent regarding risk. [9]"
          ],
          [
            "Concurrent or recent corticosteroid exposure",
            "Review all steroid use; avoid repeat corticosteroid-containing block within 3 months or longer in patients already receiving corticosteroids. [9]"
          ]
        ]
      }
    },
    {
      "id": "disposition-and-follow-up",
      "eyebrow": "Disposition",
      "heading": "Build follow-up around recurrence, medication exposure, and diagnostic change",
      "intro": "Discharge planning should prevent return visits caused by undertreated attacks, medication overuse, or evolving secondary disease.",
      "paragraphs": [
        "A headache diary can help monitor response to treatment and identify patterns relevant to ongoing management. [5] For recurrent migraine, document acute-treatment days rather than only total doses, because medication overuse thresholds are defined by days of use per month. [8]",
        "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. [8][20]"
      ],
      "bullets": [
        "Ask patients to record attack timing, associated symptoms, acute medication days, treatment response, and new neurologic or systemic features. [5][8]",
        "Give explicit return precautions for sudden-onset severe headache, new neurologic deficit, altered consciousness, or other new secondary-headache red flags. [18][19][20]",
        "Review frequent use of triptans, opioids, codeine, ergotamine, NSAIDs, or paracetamol for possible medication overuse. [8]"
      ],
      "subsections": [],
      "table": {
        "caption": "Medication-use thresholds relevant to medication-overuse headache. [8]",
        "columns": [
          "Acute medication class",
          "Use frequency defining overuse"
        ],
        "rows": [
          [
            "Triptans, opioids, codeine, or ergotamine",
            "At least 10 days per month. [8]"
          ],
          [
            "Simple analgesics, including paracetamol and NSAIDs",
            "At least 15 days per month. [8]"
          ]
        ]
      }
    }
  ],
  "faq": [
    {
      "question": "Does relief after a migraine cocktail exclude subarachnoid hemorrhage or another secondary headache?",
      "answer": "No. ACEP policy states that response to therapy should not be used as the sole diagnostic indicator of headache etiology; continue evaluation when the initial history or examination leaves meaningful concern for secondary headache. [15]"
    },
    {
      "question": "What should follow a nondiagnostic head CT when subarachnoid hemorrhage remains a concern?",
      "answer": "Lumbar puncture is a recommended second-line test in a CT/LP strategy. CT followed by CTA is also described as reasonable, but available evidence does not establish a universally preferred strategy. [1][16]"
    },
    {
      "question": "Which acute medications should raise concern for medication-overuse headache?",
      "answer": "Overuse is defined as triptans, opioids, codeine, or ergotamine on at least 10 days monthly, or simple analgesics such as NSAIDs or paracetamol on at least 15 days monthly. [8]"
    },
    {
      "question": "What are evidence-based rapid treatments for cluster headache?",
      "answer": "Supported acute options include subcutaneous sumatriptan, intranasal sumatriptan or zolmitriptan, and high-flow oxygen delivered through a non-rebreather mask. [6]"
    }
  ],
  "references": [
    {
      "number": 1,
      "title": "Shifts in Diagnostic Testing for Headache in the ...",
      "detail": "jamanetwork.com",
      "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2817836",
      "authors": "jamanetwork.com",
      "host": "jamanetwork.com"
    },
    {
      "number": 2,
      "title": "Headache management: pharmacological approaches | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/15/6/411",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com"
    },
    {
      "number": 3,
      "title": "a review of the evidence and consensus recommendations",
      "detail": "rapm.bmj.com",
      "url": "https://rapm.bmj.com/content/rapm/early/2025/07/02/rapm-2025-106718.full.pdf",
      "authors": "rapm.bmj.com",
      "host": "rapm.bmj.com"
    },
    {
      "number": 4,
      "title": "Headaches",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/334/7587/254",
      "authors": "www.bmj.com",
      "host": "www.bmj.com"
    },
    {
      "number": 5,
      "title": "Acute treatment of migraine in children and adolescents",
      "detail": "ep.bmj.com",
      "url": "https://ep.bmj.com/content/106/6/358",
      "authors": "ep.bmj.com",
      "host": "ep.bmj.com"
    },
    {
      "number": 6,
      "title": "Managing cluster headache | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/19/6/521",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com"
    },
    {
      "number": 7,
      "title": "Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/329/7479/1369/rapid-responses",
      "authors": "www.bmj.com",
      "host": "www.bmj.com"
    },
    {
      "number": 8,
      "title": "Migraine-advanced preventative treatments: the British Association for the Study of Headache Clinical Practice Recommendations and Consensus Guidance | Journal of Neurology, Neurosurgery & Psychiatry",
      "detail": "jnnp.bmj.com",
      "url": "https://jnnp.bmj.com/content/early/2026/07/16/jnnp-2026-339062",
      "authors": "jnnp.bmj.com",
      "host": "jnnp.bmj.com"
    },
    {
      "number": 9,
      "title": "Peripheral nerve blocks for headache disorders | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/21/1/30",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com"
    },
    {
      "number": 10,
      "title": "Subarachnoid hemorrhage - Symptoms, diagnosis and treatment | BMJ Best Practice US",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/415",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com"
    },
    {
      "number": 11,
      "title": "Diagnosis and management of migraine in ten steps",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41582-021-00509-5",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 12,
      "title": "Migraine | Nature Reviews Disease Primers",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41572-021-00328-4",
      "authors": "www.nature.com",
      "host": "www.nature.com"
    },
    {
      "number": 13,
      "title": "Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0196064402900004",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 14,
      "title": "Therapeutic guidelines for headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/chapter/handbook/abs/pii/S0072975210970140",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 15,
      "title": "Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0196064408014637",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 16,
      "title": "Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467915013864",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com"
    },
    {
      "number": 17,
      "title": "Primary Care Management of Headache - Oxford Academic",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/milmed/article/187/9-10/e1091/6504461",
      "authors": "academic.oup.com",
      "host": "academic.oup.com"
    },
    {
      "number": 18,
      "title": "The Diagnostic Evaluation of Secondary Headache Disorders",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2010.01841.x",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com"
    },
    {
      "number": 19,
      "title": "Clinic and Emergency Room Evaluation and Testing of ...",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.12648",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com"
    },
    {
      "number": 20,
      "title": "Headache diagnosis and treatment: A pilot knowledge and ...",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14801",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com"
    },
    {
      "number": 21,
      "title": "Imaging and physiology across the high–low cerebrospinal fluid pressure spectrum: Navigating diagnostic uncertainty in headache practice - Callen - 2026 - Headache: The Journal of Head and Face Pain - Wiley Online Library",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.70096?af=R",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com"
    },
    {
      "number": 22,
      "title": "Diagnostic workup of acute headache and subarachnoid ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ene.16385",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 23,
      "title": "“Code Headache”: Development of a protocol for ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ene.16484",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    },
    {
      "number": 24,
      "title": "Diagnostic Accuracy and Application of Subarachnoid ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1111/acem.70087",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com"
    }
  ],
  "editorialNote": "Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.",
  "citations": [
    {
      "number": 1,
      "title": "Shifts in Diagnostic Testing for Headache in the ...",
      "detail": "jamanetwork.com",
      "url": "https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2817836",
      "authors": "jamanetwork.com",
      "host": "jamanetwork.com",
      "snippet": "by DG Mark · 2024 · Cited by 13 — When CT is nondiagnostic and clinical suspicion remains high, lumbar puncture (LP) is the recommended second-line test (CT-LP approach). However",
      "score": 0.48206395
    },
    {
      "number": 2,
      "title": "Headache management: pharmacological approaches | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/15/6/411",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com",
      "snippet": "Box 1\n\n### Acute management of migraine\n\nAcute migraine management\n\nNational Institute of Health and Care Excellence (NICE) guidelines\n\n1. Combination therapy: triptan+non-steroidal anti-inflammatory drug (NSAID) or paracetamol+antiemetic\n2. Alternatively (per patient request):\n\n    a single agent (",
      "score": 0.459586
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    {
      "number": 3,
      "title": "a review of the evidence and consensus recommendations",
      "detail": "rapm.bmj.com",
      "url": "https://rapm.bmj.com/content/rapm/early/2025/07/02/rapm-2025-106718.full.pdf",
      "authors": "rapm.bmj.com",
      "host": "rapm.bmj.com",
      "snippet": "Clinical implications Parenteral pharmacological treatment typically includes a combination of DHE, NSAIDs, antiemetics, antiepileptics, magnesium, corticosteroids, lidocaine, and ketamine, all tailored to the specific headache patient.151 These recom-mendations aim to provide additional options for",
      "score": 0.39768162
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      "url": "https://www.bmj.com/content/334/7587/254",
      "authors": "www.bmj.com",
      "host": "www.bmj.com",
      "snippet": "by G Fuller · 2007 · Cited by 11 — Try to identify triggers and suggest the patient avoids these. Make an acute treatment plan—analgesics with or without antiemetics or triptans.",
      "score": 0.391802
    },
    {
      "number": 5,
      "title": "Acute treatment of migraine in children and adolescents",
      "detail": "ep.bmj.com",
      "url": "https://ep.bmj.com/content/106/6/358",
      "authors": "ep.bmj.com",
      "host": "ep.bmj.com",
      "snippet": "by D Cromb · 2021 · Cited by 3 — A headache diary is useful in monitoring response to migraine treatment. Early, initial treatment with ibuprofen and paracetamol is effective and recommended",
      "score": 0.2624416
    },
    {
      "number": 6,
      "title": "Managing cluster headache | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/19/6/521",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com",
      "snippet": "### Lithium\n\nThe evidence is limited for lithium33 36 37 however it is generally accepted as a reasonable second-line option. It is more commonly used in chronic compared with episodic cluster headache but its potential impact on thyroid function and risk of interference with diuresis may complicate",
      "score": 0.17874108
    },
    {
      "number": 7,
      "title": "Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials",
      "detail": "www.bmj.com",
      "url": "https://www.bmj.com/content/329/7479/1369/rapid-responses",
      "authors": "www.bmj.com",
      "host": "www.bmj.com",
      "snippet": "The disadvantages of chlorpromazine are its anticholinergic and antidopaminergic side effects. These include sedation, dry mouth, postural hypotension, and extra-pyramidal reactions. Metoclopramide shares the propensity to produce dystonic reactions but is generally less sedating. These side effects",
      "score": 0.16466448
    },
    {
      "number": 8,
      "title": "Migraine-advanced preventative treatments: the British Association for the Study of Headache Clinical Practice Recommendations and Consensus Guidance | Journal of Neurology, Neurosurgery & Psychiatry",
      "detail": "jnnp.bmj.com",
      "url": "https://jnnp.bmj.com/content/early/2026/07/16/jnnp-2026-339062",
      "authors": "jnnp.bmj.com",
      "host": "jnnp.bmj.com",
      "snippet": "#### Consensus\n\nAll options can be used in patients over 65 years of age taking individual contraindications into account.\n\n#### Supporting evidence and rationale\n\nTreatment selection in patients over 65 years requires consideration of additional factors, including analgesia for other pain condition",
      "score": 0.15583521
    },
    {
      "number": 9,
      "title": "Peripheral nerve blocks for headache disorders | Practical Neurology",
      "detail": "pn.bmj.com",
      "url": "https://pn.bmj.com/content/21/1/30",
      "authors": "pn.bmj.com",
      "host": "pn.bmj.com",
      "snippet": "Having identified someone as suitable for a peripheral nerve block, we find it helps to show them an illustration of the peripheral cranial nerve to be injected (figure 1). The written consent should include the known complications of any invasive procedure, such as bleeding or infection at the inje",
      "score": 0.14984241
    },
    {
      "number": 10,
      "title": "Subarachnoid hemorrhage - Symptoms, diagnosis and treatment | BMJ Best Practice US",
      "detail": "bestpractice.bmj.com",
      "url": "https://bestpractice.bmj.com/topics/en-us/415",
      "authors": "bestpractice.bmj.com",
      "host": "bestpractice.bmj.com",
      "snippet": "open menu\n\n# Subarachnoid hemorrhage\n\nWhen viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.\n\n## Summary\n\nSubarachnoid hemorrhage (SAH) presents as a sudden severe headache, ofte",
      "score": 0.40995342
    },
    {
      "number": 11,
      "title": "Diagnosis and management of migraine in ten steps",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41582-021-00509-5",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "### First-line medication\n\nOver-the-counter analgesics are used worldwide for acute migraine treatment44.\"). Those with proven efficacy include non-steroidal anti-inflammatory drugs (NSAIDs), and the strongest evidence supports use of acetylsalicylic acid, ibuprofen and diclofenac potassium as first",
      "score": 0.40995342
    },
    {
      "number": 12,
      "title": "Migraine | Nature Reviews Disease Primers",
      "detail": "www.nature.com",
      "url": "https://www.nature.com/articles/s41572-021-00328-4",
      "authors": "www.nature.com",
      "host": "www.nature.com",
      "snippet": "Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Sp",
      "score": 0.16281913
    },
    {
      "number": 13,
      "title": "Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0196064402900004",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Title: Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache - ScienceDirect\n# Clinical Policy Clinical policy: Critical issues in the evaluation and management of patients presenting to the emergency department with ",
      "score": 0.64344186
    },
    {
      "number": 14,
      "title": "Therapeutic guidelines for headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/chapter/handbook/abs/pii/S0072975210970140",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "They represent a systematic evaluation of the evidence base for the acute and prophylactic treatment of migraine and trigeminal autonomic cephalalgias generated by international experts in the field of headache medicine. The variability in diagnosis and appropriate treatment of primary headache diso",
      "score": 0.62495816
    },
    {
      "number": 15,
      "title": "Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0196064408014637",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Title: Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache - ScienceDirect\n# Pain management/clinical policy Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to th",
      "score": 0.599087
    },
    {
      "number": 16,
      "title": "Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0736467915013864",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "### BMJ (2010) \n   S.H. Bø _et al._\n### Acute headache: a prospective diagnostic work-up of patients admitted to a general hospital\n\n### Eur J Neurol (2008) \n   S.A. Matloob _et al._\n### Evaluation of the impact of the Canadian subarachnoid haemorrhage clinical decision rules on British practice\n\n##",
      "score": 0.49948794
    },
    {
      "number": 17,
      "title": "Primary Care Management of Headache - Oxford Academic",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/milmed/article/187/9-10/e1091/6504461",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "by JJ Sico · 2022 · Cited by 6 — This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with",
      "score": 0.20774499
    },
    {
      "number": 18,
      "title": "The Diagnostic Evaluation of Secondary Headache Disorders",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2010.01841.x",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com",
      "snippet": "The above studies confirm that the red flags of “sudden onset headache” and “abnormal neurologic exam” are more predictive for secondary",
      "score": 0.33908364
    },
    {
      "number": 19,
      "title": "Clinic and Emergency Room Evaluation and Testing of ...",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.12648",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com",
      "snippet": "The mnemonic SNOOP for the identification of “red flags” has been developed to help with the evaluation of headache. Systemic symptoms – such",
      "score": 0.32895017
    },
    {
      "number": 20,
      "title": "Headache diagnosis and treatment: A pilot knowledge and ...",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14801",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com",
      "snippet": "The SNNOOP10 red-flag symptoms provide a well-established guideline for secondary headache screening and ED referral.30, 41 Headache pattern",
      "score": 0.3093475
    },
    {
      "number": 21,
      "title": "Imaging and physiology across the high–low cerebrospinal fluid pressure spectrum: Navigating diagnostic uncertainty in headache practice - Callen - 2026 - Headache: The Journal of Head and Face Pain - Wiley Online Library",
      "detail": "headachejournal.onlinelibrary.wiley.com",
      "url": "https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.70096?af=R",
      "authors": "headachejournal.onlinelibrary.wiley.com",
      "host": "headachejournal.onlinelibrary.wiley.com",
      "snippet": "A patient with IIH who subsequently developed a spinal CSF leak and, after repair, developed acute hydrocephalus. (A) Sagittal noncontrast CT of the head 5 years before SIH symptom onset demonstrating suprasellar cistern herniation with flattening of the pituitary gland (arrow). (B) Sagittal T1 post",
      "score": 0.30040732
    },
    {
      "number": 22,
      "title": "Diagnostic workup of acute headache and subarachnoid ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ene.16385",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "by K Aaseth · 2024 · Cited by 6 — The main purpose of this study was to describe the diagnostic properties of head CT and cerebrospinal fluid (CSF) spectrophotometry for",
      "score": 0.25899354
    },
    {
      "number": 23,
      "title": "“Code Headache”: Development of a protocol for ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/ene.16484",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "by JA Membrilla · 2024 · Cited by 9 — The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify",
      "score": 0.21790321
    },
    {
      "number": 24,
      "title": "Diagnostic Accuracy and Application of Subarachnoid ...",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/10.1111/acem.70087",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "Subarachnoid hemorrhage is a critical diagnosis associated with acute onset headaches, often described as a “thunderclap headache,” and is",
      "score": 0.18911676
    }
  ],
  "publishedAt": "2026-08-21T01:40:43.240531+00:00",
  "updatedAt": "2026-08-21T01:40:43.240531+00:00",
  "readingMinutes": 6,
  "slug": "acute-headache"
}