Headache MDM

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Headache MDM

Last reviewed: March 2026

MDM Templates

Benign Headache

Based on history and normal neurological exam I have low suspicion for intracranial hemorrhage (including SAH), intracranial mass causing mass effect, meningitis/encephalitis, temporal arteritis, acute angle-closure glaucoma, CO poisoning, cerebral venous sinus thrombosis, or other emergent intracranial process.

Presentation most consistent with a benign primary headache in this nontoxic patient with stable vitals and no focal neurological symptoms.
Recommend rest, hydration, and analgesia.

Disposition: Discharge home with strict return precautions for sudden severe headache, worst headache of life, fever, neck stiffness, vision changes, focal weakness, or altered mental status. Instructions for prompt primary care follow up.

Clinical Education

Migraine Treatment

Level A – Highly Recommended/”Must Offer”:

  • Prochlorperazine 10mg IV (+ diphenhydramine 25mg to reduce akathisia risk by 61%)
  • Greater Occipital Nerve Block (GONB)

Level B – Probably helps/”Should Offer”:

  • Metoclopramide 10mg IV
  • Ketorolac 15mg IV
  • Sumatriptan 6mg SQ
  • Supraorbital Nerve Block (SONB)

Level A – AVOID/Must NOT Offer:

  • Hydromorphone IV — evidence shows it is inferior and associated with worse outcomes

Practical cocktail approach: Prochlorperazine 10mg IV + Diphenhydramine 25mg IV + Ketorolac 15mg IV remains the most commonly used first-line combination. Add dexamethasone 10mg IV for headache recurrence prevention (NNT ~9 at 72 hours).

Key teaching point: Ketorolac alone is among the least effective single agents for migraine. Its value is primarily in combination therapy. Prochlorperazine and metoclopramide are the workhorses.

Source: Robblee J et al. “2025 guideline update: acute treatment of migraine for adults in the ED.” Headache. 2025/2026. PubMed

Red Flags – SNNOOP10

The SNNOOP10 mnemonic is the current standard for screening secondary headache causes:

Flag Feature Consider
S Systemic symptoms (fever, weight loss, cancer hx) Meningitis, malignancy, GCA
N Neurologic signs (focal deficit, AMS, seizure) Mass, stroke, hemorrhage
N New onset or sudden onset SAH, CVT, dissection
O Onset after age 50 GCA, mass, hemorrhage
O Other associated (LOC, onset with exertion/Valsalva) SAH, Chiari, posterior fossa lesion
P Positional component CSF leak (low pressure), IIH (high pressure)
P Precipitated by Valsalva/cough/exercise Chiari, posterior fossa, SAH
P Progressive or new pattern Mass, SDH, medication overuse
P Pregnancy or postpartum CVT, pre-eclampsia/eclampsia, pituitary apoplexy
P Painful eye with autonomic features Acute angle-closure glaucoma, cavernous sinus pathology

Source: Do TP et al. “Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list.” Neurology. 2019. PMC

Ottawa SAH Rule

The Ottawa SAH Rule is validated for alert patients (≥15 years) with new severe non-traumatic headache reaching maximum intensity within 1 hour. Investigation is required if ANY of the following are present:

  • Age ≥40
  • Neck pain or stiffness
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (instantly peaking pain)
  • Limited neck flexion on exam

Performance: 100% sensitivity (95% CI 97.2–100%), 15.3% specificity. The rule is designed to be a pure rule-out tool — if no criteria are met, SAH is effectively excluded. The low specificity means most positives will not have SAH, but all SAH patients will screen positive.

Source: Perry JJ et al. JAMA. 2013;310(12):1248-1255. MDCalc

CT Timing and LP Decision

The critical question in headache workup is whether a negative CT is sufficient to rule out SAH, or whether LP is also needed.

<6 hours from onset: Modern multi-detector CT has near 100% sensitivity for SAH within 6 hours of headache onset (Perry et al. 2011; validated in multiple subsequent studies). The 2019 ACEP clinical policy states non-contrast CT is sufficient for ruling out SAH in this window. LP is generally not required.

6–12 hours: Recent data (Defined et al. 2022, 10-year analysis) suggests modern CT sensitivity remains ~100% for aneurysmal SAH out to 12 hours and 99.2% for all SAH. Practice is evolving, but many institutions still proceed to LP or CTA in this window.

>12 hours: CT sensitivity begins to decline meaningfully. Further evaluation with LP or CTA is recommended if clinical suspicion remains.

LP interpretation for SAH:

  • Tube 1 vs Tube 4 RBC count: decreasing RBC count suggests traumatic tap; stable or rising count is concerning for SAH
  • Xanthochromia: most specific finding for SAH (takes 6–12 hours to develop after hemorrhage)
  • Opening pressure: elevated pressure may suggest SAH, CVT, or IIH

CTA vs LP – Shifting Practice

A large cohort study of 198,109 ED encounters (2015–2021) showed CTA use increased 6-fold relative to LP for headache evaluation, with a 33% increase in detection of unruptured intracranial aneurysms and no significant change in missed SAH or bacterial meningitis diagnoses.

CTA is increasingly being used as an alternative to LP after a negative CT, particularly in the 6–12 hour window. CTA can identify aneurysms that may warrant neurosurgical follow-up even if they haven’t ruptured. However, this approach detects incidental unruptured aneurysms whose long-term management implications remain unclear.

Source: Shifts in Diagnostic Testing for Headache in the ED, 2015-2021. JAMA Netw Open. 2024. PMC

References

  1. 2025 AHS Guideline Update: Acute Treatment of Migraine for Adults in the ED. Robblee J et al. Headache. 2025/2026. PubMed
  2. ACEP Clinical Policy: Acute Headache Diagnosis and Management in the ED. Godwin SA et al. Ann Emerg Med. 2019;74(4):e41-e74. PubMed
  3. Red and Orange Flags for Secondary Headaches: SNNOOP10 List. Do TP et al. Neurology. 2019;92(3):134-144. PMC
  4. Ottawa SAH Rule Validation. Perry JJ et al. JAMA. 2013;310(12):1248-1255. MDCalc
  5. Sensitivity of Early CT to Exclude Aneurysmal SAH. Perry JJ et al. Stroke. 2011;42(5):1210-1215. AHA Journals
  6. Sensitivity of Modern Multislice CT for SAH at Incremental Timepoints. Defined et al. J Neuroradiol. 2022. PubMed
  7. Shifts in Diagnostic Testing for Headache in the ED, 2015-2021. JAMA Netw Open. 2024. PMC
  8. Prospective Implementation of the Ottawa SAH Rule and 6-Hour CT Rule. Perry JJ et al. Stroke. 2020;51(2):424-430. AHA Journals
  9. Subarachnoid Hemorrhage: Recognition, Workup and Diagnosis Deep Dive. Emergency Medicine Cases. Ep 194. Link
  10. LITFL: Headache Red Flags. Link

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