When Should I Go to the ER for a Headache?

Written by Cherilyn Cecchini, MD | Reviewed by Katie E. Golden, MD Published on February 15, 2022

Key takeaways:

• Headaches can be scary, especially if you have never had a bad one before. But most headaches aren’t life-threatening or related to anything wrong with your brain. 
• On rare occasions, a headache can be a symptom of something else going on. There are some red-flag symptoms that can help you know when it’s time to go to the ER.
• Some people with recurrent headaches still need to go to the ER from time to time for pain relief. There are intravenous (IV) medications that can help when a headache feels severe.

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Headaches can be hard to ignore. That’s because they are nagging and painful, but also because it’s easy to worry that they mean something is wrong. And so people go to the emergency room (ER) for their headache to make sure they’re OK or simply to get some relief. But sometimes it can be hard to know if you really need to make a trip to the ER. And the last thing you need when dealing with a headache is a hard decision. So we’ll provide some information to help you know when it’s time to get help — and what to expect when you arrive at the ER.

How do I know if my headache is serious? 

Headaches are separated into two categories: primary and secondary. 

Primary headaches might be painful, but they aren’t dangerous. The cause is increased activity of pain receptors in the head, rather than a serious medical condition or something else going on in the body. Examples of primary headaches are migraines, tension headaches, and cluster headaches. 

Secondary headaches are ones that signal something else going on. And that other condition can range from something minor — like hunger or a cold — to life-threatening — like a brain bleed or infection. Some of the more serious causes of a secondary headache include:

• Head injuries that lead to bleeding in the brain
• Stroke 
• Meningitis
• Brain swelling or extra fluid in the brain
• Brain tumors

Many times people have an internal sense when a headache feels like a primary headache. This is partly because people with a migraine or tension headache have often had them before, so they’re familiar with the symptoms. But if you’re experiencing a new or different headache for the first time, there are some red-flag symptoms that can help you know when it’s time to seek emergency care.

When to go to the ER for a headache

Some symptoms that occur alongside headaches could be a sign of something more dangerous. (Although they can happen with regular primary headaches, too). It’s a good idea to go to the ER if:

• You have a fever, neck stiffness, or new rash. These could be signs of meningitis, a dangerous infection around the brain.
• Your headache starts in seconds and escalates to severe within minutes. Bleeding in the brain can cause headaches like this. 
• You are experiencing the worst pain or headache in your life.
• Your headache is noticeably worse when you are lying down. This can be a sign of increased pressure in the brain, which can happen with tumors or fluid.
• You have any severe lethargy, disorientation, confusion, or behavioral changes. 
• You lose consciousness.
• You have pain that starts abruptly during moments of intense exertion, like exercise or sexual intercourse.

Symptoms aren’t the only reason someone should seek emergency care. Certain circumstances or characteristics can also make a headache a high-risk event. These include:

• Age: Something else might be going on if you’re older than 50 years old and experience a new headache you have never had before.
• Blood-thinning medications: These medications make bleeding in the brain more likely.

• Immune system conditions: Conditions that affect the immune system, like HIV, put you at higher risk for infection. 
• Cancer: Cancer can put you at higher risk for metastatic tumors in the brain.
• Pregnancy: A headache in someone who is pregnant could be a symptom of a blood clot or high blood pressure.

Diagnosing the cause of a headache isn’t the only reason to go to the ER. Even if you know the cause of your headache (like a bad migraine), sometimes you’ll need IV medications to get relief when nothing is helping at home.

ER headache protocol

Once you arrive at the ER, the first priority will be to figure out what is causing your symptoms. Sometimes healthcare providers can figure this out based on the way you describe your headache or a physical exam. But if there’s any doubt as to whether you have a primary or secondary headache, they may need to do more testing. This can involve blood work, a CT scan, or sometimes a procedure called a “lumbar puncture.”

The second priority will be to get you some relief from the pain. There are many different medications that can help with headaches. And a lot of times this depends on what type of headache you have as well as other medical conditions. Treatments that often help include:

• IV fluids 
• Ketorolac (Toradol)
• Magnesium
• Anti-nausea medications, like ondansetron (Zofran), prochlorperazine (Compro), metoclopramide (Reglan) or chlorpromazine (Thorazine)
• Diphenhydramine (Benadryl)

The bottom line

Headaches can be extremely uncomfortable and even scary, especially if you have never had one. And certain medical conditions that cause headaches can be dangerous. These conditions tend to cause severe pain or have other symptoms like a fever, lethargy, or confusion. It helps to know these signs, so you know when to seek emergency care for yourself or a loved one. But you don’t need to have a life-threatening emergency to go to the ER for pain relief. Emergency care providers are trained in how to make sure you are OK and in ways to alleviate your symptoms.