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Review Headache Headache in the Emergency Room Kourosh Kahkeshani and Huma U Sheikh Mount Sinai Hospital, New York, NY, US H eadache is seen in the emergency room (ER) on a daily basis and is a vague symptom, which can be a part of many different types of conditions and diseases. Although most people who come to the ER will have a benign headache, it is important to make sure that dangerous causes of headache are ruled out. There are a number of features that may alert someone to a secondary cause of headache. This article highlights two specific secondary headache syndromes, including carotid dissection and reversible cerebral vasoconstriction syndrome. It also broadly points out other possible causes of secondary headache. The last section focuses on a common primary headache that presents to the ER, migraine and its treatment. Keywords Identifying secondary headaches in the emergency room Secondary, emergency room, headaches, SNOOP, migraine In 2008 alone (according to most recent data), there were over 3 million visits to the emergency room (ER) where headache was the primary complaint, in the US. 1 Headache comprised a little over 2% of all ER visits, making it one of the most common neurological complaints in the ER. 1 Disclosure: Kourosh Kahkeshani and Huma U Sheikh have nothing to declare in relation to this article. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: January 4, 2017 Accepted: April 4, 2017 Citation: US Neurology, 2017;13(2):94–8 Corresponding Author: Huma U Sheikh, Mount Sinai Hospital-Downtown, 10 Union Square, New York, NY 10003, US. E: hsheikh@chpnet.org When all the reasons are tallied, the most common etiology of headache was a primary headache diagnosis; of which migraine was the most common. 1 However, when someone presents to the ER with a headache, it is imperative for the physician to rule out more dangerous or life-threatening causes of headaches. Therefore, it is important to have a systematic approach to evaluating a patient with headache. One of the first steps in the ER when treating a patient with headache is to obtain a thorough history and conduct a physical assessment in order to identify red flags and rule out secondary causes of the disorder. Some of the important elements to discern include determining if there is a history of primary headache syndrome, along with the patient’s family and medical history and past medication use. 2 It is also vital to characterize the headache in detail, including build up of severity, location, associated symptoms such as migrainous or autonomic features, and exacerbating or alleviating factors. A change in headache characteristics that deviate from a patient’s baseline headache may allude to a new underlying process and possibly provide insight into secondary causes of headache. 3 Certain features in the patient’s history can point to a specific etiology, although it is also important to consider a wide range of differential diagnoses so that life-threatening conditions are not overlooked. A mnemonic that can help to determine if there may be a secondary cause for headache is “SNOOP.” 4 The “S” stands for systemic, including presence of fever, weight loss or other pain, including body and muscle pain. The “N” stands for neurological, or cases in which there are other neurological signs with headache, including a focal sign on physical examination. The “O” stands for onset, which includes a sudden onset of a severe headache, and is widely referred to as the “thunderclap.” A thunderclap headache is one that comes on suddenly, within seconds, and is severe from onset. In general, these types of headache are a cause for concern. The second “O” stands for older age; usually the first onset of a headache in someone older than 40 needs further workup. The “P” refers to a change in pattern, with a prior history of primary headaches, worsening of the severity or frequency can be a sign of a secondary cause. 4 Other concerning signs are unilateral or “side-locked” headaches that may point to a mass, lesion, or stroke. Headaches that are associated with visual changes or tinnitus may point to disorders causing increased intracranial pressure. Patients who are immunocompromised, including those with 94 TOUCH ME D ICA L ME D IA