Headaches are one of the most common reasons someone goes to the emergency room (ER). And they come in all sorts of shapes and sizes. They can be sharp, dull, on the left, on the right. Sometimes they are mild and slow us down a bit. Other times they are severe and stop us in our tracks. But no matter what a headache feels like, it can be hard to ignore. And the last thing someone with a headache needs is an additional worry that something is wrong. So here, we will try to provide a little bit of guidance to ease your mind . . . even when your head feels like it’s about to explode.


What causes a headache?


There are many different reasons that people get headaches. Sometimes there is an identifiable cause, like a concussion or a sinus infection. Or a screaming child and not enough coffee. But more commonly, it can be hard to pinpoint exactly why the headache started.


It helps to think of headaches in two categories: headaches that are truly just headaches, and headaches that are a symptom of something else.


Primary headaches are caused by activated pain receptors in the head. In other words, they are not a symptom of some other problem in the brain or the body. Some examples of primary headaches include:

  • Migraine headaches. These tend to be on one side of the head, throbbing in nature, and are often accompanied by symptoms like nausea, vomiting, and light and sound sensitivity.
  • Tension headaches. These headaches are often on both sides of the head, and have a squeezing or tightening quality.
  • Cluster headaches. These headaches can be pretty severe, and they often feel like a sharp, stabbing pain behind the eye or in the temple area.


Even though these are common types of headaches, experts and researchers still don’t fully understand what causes them.


Secondary headaches, on the other hand, are a sign of something else going on in the brain or the body. They are a symptom of another condition or disease, and often that problem is outside the brain or nervous system. Examples include:

  • Hunger or thirst
  • Fever
  • High blood pressure
  • Too little sleep . . . or too little coffee
  • Nasal or sinus congestion


While it’s rare, secondary headaches can also result from something going on in the brain, like bleeding, too much fluid, a tumor, or an infection. And it’s these more serious causes of headaches that require more immediate medical evaluation.


When should I go to the ER for my headache?


It’s not always easy to tell what’s causing your headache. And it can be even harder to think clearly about your symptoms while the headache is clouding your thoughts. But there are some clues and circumstances that can help you figure out if you should see a healthcare provider.


Let’s break these down into two categories: details about the headache, and details about you.


Below is a list of headache qualities and symptoms that are suggestive of something else going on that should be checked out:

  • Sudden or abrupt onset headache, in which the pain goes from mild to severe in a matter of minutes
  • The headache is not only severe but unfamiliar to you (especially if you are over the age of 50 and have never had a headache like this before)
  • The headache just keeps getting worse and worse, and nothing seems to help it
  • New confusion, disorientation, or the person with the headache is very difficult to arouse
  • Inability to walk
  • Loss of vision
  • Fever


Keep in mind that many of these symptoms can also be seen in non-life-threatening headaches, or primary headaches, too. Migraine headaches, for example, often feel severe, come out of nowhere, and frequently cause vision symptoms.


There are also some details about the person with the headache that make them slightly higher risk for a serious underlying cause. These include:

  • A recent fall or head trauma
  • Anticoagulation, or blood-thinning medications (such as coumadin, Xarelto, Eliquis, Pradaxa, Plavix, aspirin)
  • Pregnancy
  • HIV, or other conditions that lead to a weakened immune system
  • Prior or active cancer


Many people are rather intuitive about their bodies and can sense when something feels wrong or abnormal for them. So if you are worried, don’t hesitate to head to the nearest ER to get some help.


What happens in the ER when someone has a headache?


Anytime we are treating someone in the ER for a headache, we have two main goals. Actually, we have three, but I wanted to stick with the two-item list theme I’ve got going here. I kid, there’s just two:

  • Figure out what’s causing the headache
  • Make the headache go away


Many times, diagnosing the headache can be done based on symptoms alone. Other times, we will order additional testing. This often involves a CT scan of the brain, and possibly blood tests. But not everyone needs these tests.


The treatment for a headache typically involves intravenous (IV) medications. And the best medications depend on the person and the cause of their headache. Fortunately, there is a small arsenal of options that are highly effective for headaches. Some of the more commonly used medications include:

  • IV fluids (there are few things saltwater can’t cure, am I right?)
  • Magnesium (that’s right, this mineral has many different medical uses)
  • IV versions of NSAIDs (such as ketorolac, which is like a stronger version of ibuprofen)
  • Anti-nausea medicines (even if you don’t have severe nausea or vomiting with your headaches, medications like metoclopramide is particularly helpful for headaches)
  • Diphenhydramine (the fancy generic name for Benadryl)


Hopefully, after a magical cocktail of medications that has cured your headache, you can head home to rest your tired, pain-free head on your pillow.