Q&A 008 Which Headaches Belong in the ER?

⏱ 10 min read

Dr. Hayes Q&A · No. 008

By Eleanor Hayes, M.D. · Hospitalist

The Question

“I’ve lived with migraines for more than twenty years. Most headaches I can ride out with medication and a dark room. But a while back I read about a man who kept toughing out a headache until he collapsed from a brain bleed. Now every time one starts, I wonder whether this is just my migraine or something dangerous. Which headaches actually belong in the ER? I can’t go every time.”

— Name withheld

The Short Answer

Which headaches belong in the ER comes down to pattern, not pain. A migraine you have known for twenty years, arriving the way it always arrives, is most likely not an emergency no matter how much it hurts. What is an emergency is the unfamiliar headache: one that reaches its peak within seconds to a minute, one unlike anything you have felt in your life, or one that brings company, such as fever, a stiff neck, weakness in a limb, or slurred speech. And a long history of migraines gives you one real advantage. You know your own pattern better than anyone. The dangerous headache usually does not announce itself as “the usual one, but worse.” It announces itself as “this is different.”

Why It’s Not That Simple

Start with the reassuring part. Most people who come to an emergency room with a headache have a primary headache, meaning the headache itself is the illness: migraine or tension-type, most commonly. Secondary headaches, the ones caused by something else going wrong inside the head, are the minority. The problem is that this minority runs on a clock, and from the outside, by pain alone, the two groups look the same.

So the hospital does not ask how much it hurts. It asks about pattern.

The first pattern: how fast it peaked. If you remember only one thing from this article, make it this one. A normal headache builds. But some headaches reach maximum intensity within seconds to a minute, like a clap of thunder, which is why medicine calls them thunderclap headaches. A thunderclap headache is the classic signal of a subarachnoid hemorrhage, bleeding in the space beneath the membrane that wraps the brain, and it means calling 911 now, whatever the severity. There is a phrase patients use that ends up in charts: “the worst headache of my life.” When that sentence is spoken, the hospital moves.

The second pattern: what the headache brought with it. When a headache does not come alone, its companions decide the destination. Fever with a stiff neck means meningitis has to be ruled out. Weakness in an arm or leg, slurred speech, trouble seeing, a drooping eyelid, sudden confusion, or being hard to wake mean the brain and its blood vessels have to be checked. This is the same principle from the last installment on when a fever in an adult is actually an emergency. The number is a poor guide. The company it keeps is the real one.

The third pattern: firsts. A first-ever headache after 50. A headache that bursts on during coughing, straining, or sex. One that changes with position, worse lying down and better standing. A new headache in someone with a cancer history or a suppressed immune system. These are the items on the list doctors call red flags. Neurology has organized them into a checklist called SNNOOP10, and in a validation study of emergency room patients with a high probability of dangerous headache, applying the full list missed none of them. Sensitivity of 100 percent. Turn that around and it says something useful: a headache that trips none of these flags is very likely on the safe side of the line.

And the trap built specifically for migraine patients. This is the part I most want the reader who asked to hear. Living with migraines for decades makes you fluent in severe pain, and that fluency becomes the trap. When a subarachnoid hemorrhage arrives, the practiced interpretation is “this migraine is unusually bad,” followed by medication and waiting it out. The pattern of a thunderclap headache being filed under migraine, with the bleed found late, repeats in hospitals often enough to be a teaching point. The dividing line is a single question. Did it come the way it always comes? You carry twenty years of data in your head. If the feeling is “this is different,” that feeling is a reason for a scan.

Fairness requires the other direction too. A familiar headache repeating in its familiar form, the sheer intensity of the pain, or the fact that it drags on for days are, by themselves, weaker warning signs than people assume. Migraines hurt badly. That is what they do. You do not need the ER every time, and the list above is exactly the filter that tells you which times you do.

What I See in the Hospital

Two scenes repeat.

One is the patient whose migraine history sits on the first line of the chart. When a diagnosis is already written down, the patient, and sometimes the clinician, will try to fit the new headache inside it. A diagnosis explains things, and that is its job, but it can also become a screen that hides things. So the question we ask is not “how bad is the pain.” It is “is this the same as your usual headache, or different.” The answer to that one sentence often decides whether a CT gets ordered.

The other is the patient reassured because the painkiller worked. In the fever installment I wrote that a fever coming down with medicine is not an all-clear, and headaches follow the same rule exactly. Pain from a bleed can ease temporarily with a pill. Medication working means the symptom was muted for a while, not that the cause is absent. The information that matters is not whether the pill worked. It is how the headache began.

And one more thing. Some people come to the ER and the workup ends in a migraine diagnosis. I do not tell them the trip was wasted. A headache that arrived like a thunderclap was worth checking, and the result was simply good news.

Plain-Language Reference

What to Actually Do

· If a headache reaches its peak within seconds to a minute, call 911 regardless of how severe it feels. Do not drive yourself.
· If a headache comes with fever and a stiff neck, weakness, slurred speech, confusion, or a seizure, it is the ER.
· If you have a long migraine history, make “is this the same as always” your test. If the feeling is that this one is different, that feeling is a reason for a scan.
· Do not treat a painkiller working as an all-clear. The information that matters is how the headache began, not whether the pill helped.
· A first-ever headache after 50, one triggered by coughing, straining, or sex, or one that changes with position is not always an emergency, but it should be seen promptly, not filed away.
· A familiar headache arriving in its familiar form does not need an ER visit every time. But if the frequency or the character is drifting over months, that trend deserves an appointment of its own.

This article is for general information only and does not constitute medical advice, and reading it creates no provider-patient relationship. It cannot account for your specific situation and is not a substitute for evaluation by a licensed professional. A headache can be a symptom of a life-threatening condition. If a headache reaches its peak within seconds to a minute, or comes with fever, a stiff neck, weakness, slurred speech, vision changes, confusion, or a seizure, call 911 or go to the nearest emergency room without delay. When you are unsure, treat it as an emergency rather than waiting to see.

Take care of yourself. Nobody else will do it for you.
— Eleanor Hayes, M.D.