Headache in the Emergency Department and Rapid Access Program in Ottawa

Headache in the ED: clinical approach and rapid access pathway in Ottawa

Headache accounts for a significant proportion of emergency department (ED) visits.

While most presentations are ultimately primary headache disorders, ED clinicians must rapidly exclude dangerous secondary causes — often with limited time, incomplete histories, and constrained follow-up options. As a result, many patients leave with provisional diagnoses, persistent symptoms, or uncertainty about next steps. Headache recurrence and repeat ED visits are common.

The Rapid Access Headache Clinic was developed by neurologists and emergency physicians to bridge this gap.

Looking for our Headache in the ED clinician's guide? Click here or scroll below.

The Ottawa Headache Centre's innovative Rapid Access Headache Clinic for the ED was co-designed and is co-run by neurologists and emergency physicians.

Our goal is simple: improve diagnostic precision, reduce repeat ED visits, and ensure patients move efficiently from acute care to definitive headache management.

Through this pathway, we have achieved a median discharge-to-consultation interval of approximately 3 weeks for referred patients.

Ideal candidates for the Rapid Access Headache Clinic:

• Diagnostic uncertainty after ED evaluation

• Poorly controlled headache in the ED

• Migraine with high disability

• Frequent ED visits for headache

• Suspected cluster/TACs

• Suspected IIH without acute vision loss

• Suspected CSF-leak or low-pressure headache

• Suspicion of other secondary headache disorders after excluding life-threatening ones in the ED (e.g., SAH, bacterial meningitis excluded)

• Assessment of acute or preventive therapy initiated in the ED

Next steps

If you are an ED leader interested in joining our Rapid Access Headache Clinic program for selective patients discharged from the ED with headache, please reach out to Dr. Miguel Cortel-LeBlanc via his The Ottawa Hospital protected email.

Headache is a common emergency department (ED) presentation. Most people in the ED with headache have either a primary headache disorder or a non-dangerous secondary headache disorder. However, some patients will have time-sensitive secondary causes for their headache.

Broadly, the focus of emergency management of headache lies in:

1) Excluding dangerous secondary causes of headache

2) Treating headache effectively

For a comprehensive review on managing migraine in the ED refer to our 2023 article.

1) What are the goals in managing headache in the ED?

The initial goals to managing a patient with headache in the ED include:

1. Identify causes of secondary headache requiring urgent intervention

2. Provide effective acute treatment

3. Avoid unnecessary imaging and opioids

4. Enable safe discharge and reduce return visits

A careful history and neurological examination remain the most important diagnostic tools and determine:

• whether imaging is needed or not

• what treatments are indicated (treat headache according to phenotype)

2) What are the "red flags" of secondary causes of headache?

The mnemonic SNNOOP10 can be used to screen for secondary causes of headache:

• Systemic symptoms (fever, weight loss)

• Neoplasm history

• Neurologic deficit or abnormal exam

• Onset sudden (thunderclap)
  Remember that most headache is of sudden onset; what matters most is how instantaneously peaking headache is

• Older age at onset (>50)

• Pattern change or new headache

• Positional

• Precipitated by exertion/valsalva

• Papilledema

• Pregnancy/postpartum

• Painful eye with autonomic features

• Post-traumatic

• Pathology of immune system (HIV, immunosuppression)

• Painkiller overuse

• Progressive headache

• Previous headache history absent

Presence of red flags should prompt targeted investigations where indicated, not reflexive imaging.

The presence of SNNOOP10 features does not indicate the person has a secondary cause to headache, however the absence of all features highly suggests a primary headache disorder.

3) What are the most important parts of a headache physical examination in the ED?

Most patients with headache will have a normal physical exam.

Key common components include:

• Mental status;

• Cranial nerves
  Special attention to whether there is a dysconjugate gaze, nystagmus, or visual field defects

• Fundoscopy
  Fundoscopy can sometimes be the only clue a patient has high ICP, and foregoing it risks missing vision-threatening causes of headache

• Motor/sensory exam

• Coordination and gait

Additional components may include:

• Signs of meningismus (e.g., those with infectious symptoms or fever)

• Temporal tenderness (e.g., those with new headache after 50 years of age)

• Mandibular/oral examination in those with orofacial pain

• Ocular exam as indicated in history if suspecting primarily an ophthalmologic cause (e.g., AACG, corneal foreign body, etc.)

4) How important is fundoscopy in a headache examination?

Fundoscopy: why it matters

The most important reason to perform fundoscopy in the ED in patients presenting with headache is to exclude papilledema.

This is specially important in those who:

• Present with a new headache

• Endorse their headache is positional (e.g., worse while recumbent)

• Experience transient visual obscurations, blurry vision, or non-specific visual symptoms

• Endorse pulsatile tinnitus

Papilledema may indicate:

• Idiopathic intracranial hypertension

• Secondary causes of elevated ICP (e.g., CVST, space-occupying lesion)

Practical fundoscopy tips

• Darken the room

• Use a PanOptic (if available)

• Use the lowest diopter initially

• Ask the patient to fixate on a distant target

• Approach at ~15° temporal angle

• If a PanOptic is unavailable, consider dilating the pupils

Fundoscopy can be a challenging skill at first, however with practice and repetition it is a skillset that can be honed.

5) How is migraine aura distinguished from stroke or TIA?

Migraine aura is a transient gradual neurological symptom (or symptoms) that may precede the onset of headache whereas stroke/TIA represents a sudden cerebrovascular event that results in neurological deficits.

The two conditions can have overlapping features, and physicians should exclude stroke/TIA if doubt exists (through either neuroimaging or neurology consultation).

These features are trends and don't serve as a clinical decision rule. It is important to evaluate the symptoms within the context of the patient's risk profile (e.g., age, cerebrovascular risk factors), temporal profile of symptoms, and exam.

Retinal, brainstem, and hemiplegic aura are rare forms of migraine aura; a patient's first presentation for any of these aura variants should alarm clinicians of the possibility of stroke/TIA rather than migraine aura.

6) What type of imaging test is needed for secondary causes of headache?

Not all secondary causes of headache require imaging in the ED. A patient with acute headache attributed to trauma, for example, may have imaging omitted if they meet low risk criteria such as the Canadian CT-Head rules.

The summary below can be used as a reference when deciding what is the best imaging test to order in the ED:

SAH (within 6 hours): Non-contrast CT head (LP may still be warranted in those at very high risk)

SAH (beyond 6 hours): Non-contrast CT head + CT angiogram or LP depending on local practice

RCVS: CT angiogram

Cervical artery dissection: CT angiogram head and neck

CVST: CT venogram or MR venogram (preferred in pregnancy)

Intracranial neoplasm: MRI brain (if available)
or CT head (with contrast depending on local practice)

IIH: CT venogram (or MRI brain + venogram if available)

7) What is the most effective way of treating migraine in the ED?

The 2025 American Headache Society updated guidelines in parenteral treatment of migraine in the ED have resulted in:

• Upgrading the recommendation of prochlorperazine to "must-offer"

• Introducing greater occipital nerve blocks as a "must-offer" treatment

In general, a combination of treatments in the ED should be offered to reach pain freedom or as close to as possible.

First-line parenteral therapy:

• Prochlorperazine (or metoclopramide if prochlorperazine is unavailable)

• Greater occipital nerve blocks

• Ketorolac

• Sumatriptan

Avoid opioids — associated with poorer outcomes

Second-line parenteral therapy:

• Magnesium sulfate

• Valproic acid (if available)

• Dexamethasone (for acute treatment, however it should be offered to reduce recurrence)

• Supratrochlear, supraorbital, or sphenopalatine ganglion blocks

Other:

• DHE (ergotamine) can be considered with patients in status migrainosus who have not used triptans in 24 hours. Patients should be pre-treated with an antiemetic.

• Intravenous lidocaine, propofol, and ketamine, carry insufficient evidence to serve as mainstay treatments

8) What acute medications should patients with migraine be discharged with from the ED?

Patients discharged from the ED with migraine should be discharged with a prescription with an as needed migraine medication. Equipping patients with an effective acute migraine medication can allow them to effectively treat migraine attacks and avoid unnecessary ED visits.

Discharge acute medications

• Can include NSAIDs (i.e., diclofenac, naproxen), triptans, or gepants (maximum under 15 days per month)

• Avoid opioids

Triptans

Maximum under 10 days per month of use. Various doses are available - this guide is for reference only.

Quick acting oral triptans:

Almotriptan 12.5 mg orally daily as needed, may repeat once 2 hours later

Eletriptan 40 mg orally daily as needed, may repeat once 2 hours later

Sumatriptan 100 mg orally daily as needed, may repeat once 2 hours later

Zolmitriptan 5 mg orally daily as needed, may repeat once 2 hours later

Long acting oral triptans:

Frovatriptan 2.5 mg orally daily as needed

Naratriptan 2.5 mg orally daily as needed, may repeat once 4 hours later

Intranasal triptans:

Sumatriptan 20 mg intranasal daily as needed, may repeat once 2 hours later

Zolmitriptan 5 mg intranasal daily as needed, may repeat once 2 hours later

Subcutaneous triptans:

Sumatriptan 6 mg subcutaneously daily as needed, may repeat once 1 hour later

Gepants

Avoid in pregnancy. This is list is for reference only and on-label directions should be followed.

Ubrogepant 100 mg orally daily as needed, may repeat once 2 hours later

Rimegepant 75 mg orally daily as needed

9) When should a migraine preventive medication (i.e., daily medication) be considered for patients discharged from the ED?

Consider initiating or recommending preventives when:

• Frequent attacks (≥4 migraine days/month)

• Recurrent ED visits

• High disability associated with attacks and acute medications are ineffective

Preventives may include:

Amitriptyline 10-25 mg orally at night; can be titrated up to 50-100 mg at night

Candesartan 8 mg orally daily; can be titrated up to 32 mg orally daily (avoid in pregnancy)

Metoprolol 25 mg orally twice daily; can be titrated to 50 mg orally twice daily

Propranolol 20 mg orally twice or three times daily; can be titrated up to 80 mg orally three times daily

Topiramate 25 mg orally at night; can be titrated up every 1-2 weeks to 50 mg orally twice daily (avoid in pregnancy)

Venlafaxine 37.5 mg orally daily; can be titrated up to 150 mg orally daily

Due to tolerability and general familiarity to ED physicians, consider any of:

• Amitriptyline

• Candesartan

• Metoprolol

10) When should patients with headache discharged from the ED be referred for outpatient headache consultation?

Refer when:

• Diagnostic uncertainty

• Poorly controlled migraine attacks

• Frequent migraine attacks

• Failure of migraine preventives

• Initiating migraine preventives in the ED

• Frequent use of ED for headache

• Suspicion for cluster headache or TACs
  (i.e., side-locked headache, cranial autonomic symptoms, agitation, or restlessness)

• Suspected secondary causes of headache (after excluding dangerous causes in the ED)

• Suspected IIH (refer to neuro-ophthalmology as well, especially if there is papilledema)

• Suspected cranial neuralgias

Disclaimer

This material is provided for educational purposes and does not replace independent clinical judgment or institutional protocols. Management decisions remain the responsibility of the treating clinician.