Headache patients may present as an emergency for various reasons.

Acute Systemic Illness
The patient may have a new headache as the symptom of an acute systemic illness. Diagnosis in these cases is usually not difficult, and treatment is directed toward the underlying illness.

First or Worst Headache
The patient may have an attack of his “first or worst headache” (Edmeads, 1988), with or without a prior history of recurrent headache, or a progressively worsening headache. This presentation may be complicated by focal neurologic signs or symptoms of intractable nausea and vomiting.

“Last Straw” Syndrome
Finally, the headache may be part of a chronic headache disorder that either has failed to respond to the usual treatment or can no longer be tolerated (the “last straw” syndrome) (Edmeads, 1988). Most patients who present to the emergency department with the chief complaint of headache have a primary headache disorder or a systemic illness.

Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.