Common Symptoms
Headache
Most headaches in the outpatient setting are primary (migraine, tension), but the job is to recognize the secondary headaches that need imaging, antibiotics, or neurosurgery the same day. This page covers the can't-miss diagnoses (subarachnoid hemorrhage, meningitis, stroke, giant cell arteritis, hypertensive emergency, cerebral venous thrombosis, acute angle-closure glaucoma, CO poisoning), red flags (thunderclap, worst-of-life, fever + stiff neck, focal deficit, age > 50 with new headache, anticoagulation, Valsalva-worsening, immunocompromise), the minimum safe first-pass workup (focused history, neuro exam, BP, ESR/CRP if GCA suspected, imaging only when red flags), outpatient management of recurrent migraine and tension headache, escalation criteria, documentation patterns, and return precautions. Written for NPs, PAs, and MDs in outpatient practice.
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Common Symptoms
Headache
Why this symptom matters
The vast majority of headaches are benign primary headaches. AAFP and ACR are explicit: imaging is not recommended for uncomplicated headache without red flags. Your job is to screen for the few presentations that need urgent workup.
What must I not miss first?
- Subarachnoid hemorrhage (thunderclap)
- Meningitis / encephalitis
- Stroke / intracranial hemorrhage
- Giant cell arteritis (age >50)
- Acute angle-closure glaucoma
- CO poisoning (multiple household members, winter heating)
- Cerebral venous sinus thrombosis (postpartum, OCP, hypercoagulable)
- Brain mass — especially in immunocompromised or known cancer
Red flags — escalate or work up urgently
- Thunderclap onset (max severity <1 minute)
- Fever with meningeal signs or photophobia
- Focal neurologic deficit, seizure, or papilledema
- Altered mental status
- Age >50 with new headache pattern
- Immunocompromise or active cancer history
- Worsens with cough/Valsalva or wakes from sleep
- Recent head trauma or anticoagulation
- Jaw claudication, scalp tenderness, vision changes (GCA)
Minimum safe first-pass workup
- Focused neuro exam + funduscopy + BP
- Temperature
- ESR/CRP if GCA considered
- No routine imaging for uncomplicated headache without red flags
- If red flags: non-contrast CT head urgently; LP if SAH still suspected after negative CT
What can usually be managed outpatient
- Migraine with classic features and benign exam
- Tension-type headache
- Medication-overuse headache (taper plan)
- Cluster headache (with established diagnosis)
- Sinus, dental, or cervicogenic causes when exam supports
When to escalate to ED / higher level of care
- Any thunderclap headache
- Suspected meningitis, stroke, GCA, glaucoma, or CO poisoning
- Focal deficit or altered mental status
- Headache progressing despite first-line treatment with new red flags
What to document when the diagnosis is still uncertain
- Onset speed, severity, quality, location, triggers, prior history
- Each red flag screened — present or absent
- Neuro exam findings, funduscopy, BP, temperature
- Reasoning for or against imaging
Safety-net & return precautions to give
- Go to ED for sudden 'worst headache of life,' fever with neck stiffness, weakness/numbness, vision loss, confusion, or seizure.
- Return for headache lasting >72 hours, vomiting that won't stop, or headache that wakes you from sleep.
- Follow up in [X days] if not improving.
Educational guidance for clinicians. Not a substitute for clinical judgment. Always individualize to the patient and your local resources.
Evidence sources
- · AHS Adult Headache Guidelines
- · ACEP Clinical Policies
Review status
Last reviewed: 2026-04
Reviewed by the MyClinicianGuide editorial team. Cadence: annual.
Educational reference for licensed clinicians (NP, PA, MD, DO). Not a substitute for clinical judgment, institutional protocols, or specialty consultation. Apply in context of the full clinical picture, patient goals, and current standards of care. See About AI guidance for AI-related limitations.
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