Urgent Care · Common Complaints
Headache
Most headaches in urgent care 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), the minimum safe 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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Urgent Care · Common Complaints
Headache
Why this symptom matters
Most headaches are primary (migraine, tension). The job is to recognize the secondary headaches that need imaging, antibiotics, or neurosurgery — today.
What must I not miss first?
- Subarachnoid hemorrhage
- Meningitis / encephalitis
- Stroke
- Giant cell arteritis (in older adults)
- Hypertensive emergency
- Cerebral venous thrombosis
- Acute angle-closure glaucoma
- Carbon monoxide poisoning
Red flags — escalate or work up urgently
- Thunderclap onset (peak in seconds)
- "Worst headache of life"
- Fever + stiff neck + photophobia
- Focal neuro deficit, AMS, seizure
- Age > 50 with new headache, jaw claudication, vision change (GCA)
- Immunocompromised, anticoagulated, recent head trauma
- Headache worse with Valsalva, lying flat, or in early morning
- Eye pain with visual halos, red eye, fixed mid-dilated pupil
Immediate Management — While You Work It Up
- Dark quiet room immediately — reduce stimulation for any severe headache.
- IV access — if thunderclap, worst headache of life, focal deficit, or fever with stiff neck.
- Ketorolac 30 mg IM — first line for severe migraine in urgent care. Effective and non-sedating.
- Prochlorperazine 10 mg IV or IM plus diphenhydramine 25 mg — give diphenhydramine concurrently to prevent akathisia. Highly effective for migraine with nausea.
- IV fluids — if dehydrated or unable to tolerate oral intake.
- Do not give triptans if thunderclap onset, focal neurological deficit, fever plus stiff neck, or first severe headache of the patient's life — send to ED first.
- Do not discharge a thunderclap headache without CT and LP — subarachnoid hemorrhage has a normal CT in up to 6% of cases within 6 hours.
Minimum safe first-pass workup
- What to ask: onset (sudden vs. gradual), severity vs. usual headaches, fever, neuro symptoms, prior headache pattern, anticoagulation, recent trauma
- What to examine: vitals (especially BP), neuro exam (cranial nerves, motor, gait), neck stiffness, fundi if possible, temporal artery palpation in older adults
- POC glucose if AMS
- ESR/CRP if GCA suspected
- BP recheck if hypertensive
- Imaging only if red flags — uncomplicated migraine does not need a CT
What can usually be managed outpatient
- Recurrent migraine matching prior pattern, normal exam
- Tension-type headache, normal exam, no red flags
- Sinus or post-viral headache with congestion, no red flags
- Medication-overuse headache (counsel + taper plan)
When to escalate to ED / higher level of care
- Any thunderclap or "worst-of-life" headache
- Fever + stiff neck + photophobia
- Focal deficit, AMS, seizure
- Suspected GCA (start steroids urgently if confirmed; needs ophtho/rheum)
- Hypertensive emergency with end-organ symptoms
- Acute angle-closure glaucoma (ED + ophtho)
What to document when the diagnosis is still uncertain
- Onset, severity, character, comparison to prior headaches
- Neuro exam findings (positives AND negatives)
- "SAH / meningitis / GCA / stroke considered and ruled out today because…"
- Treatment given, response, discharge vitals, return precautions
Safety-net & return precautions to give
- Return or call 911 for sudden severe headache, fever, stiff neck, weakness, numbness, trouble speaking, vision change, fainting, seizure, or persistent vomiting.
- Return if headache pattern is new or unlike prior headaches.
- Follow up with PCP if headaches recur or escalate in frequency.
Geriatric-specific modifiers (apply on top of the above)
The guidance above applies to all adult patients seen in this setting. Layer the points below for adults 55+, geriatric (65+), and frail younger adults — they are additions, not replacements.
In adults 55+, geriatric (65+), and frail younger adults, a new headache is never routine. Older adults often present with confusion, fatigue, or dizziness rather than describing a classic headache pattern.
- Giant cell arteritis (GCA): any new headache in a patient over 50 — check ESR and CRP, palpate temporal arteries, ask about jaw claudication, scalp tenderness, and visual symptoms. Start high-dose prednisone empirically (60 mg) if suspicion is high; vision loss can be permanent and bilateral within days.
- Subdural hematoma can present days to weeks after a minor (or forgotten) fall, especially on anticoagulants — have a low threshold for CT head.
- Anticoagulated patient with a new headache — CT head, even without trauma.
- Review medication culprits — nitrates, calcium-channel blockers, SSRIs, PPIs, caffeine withdrawal.
- Avoid Beers-list agents for acute treatment: meperidine, butalbital-containing products, indomethacin, and high-dose NSAIDs in CKD/HF.
- Always check BP and screen for hypertensive emergency, CO exposure (winter, shared heating), and acute angle-closure glaucoma (eye pain, halos, mid-dilated pupil).
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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