Clinical Assessment and Risk Stratification

Headache is the most common neurological condition in the world, with more than 90% of people experiencing headaches at some point in their lives.

Most headache presentations to the ED are due to primary headaches, usually tension headaches or migraine.

Most of these patients will be discharged, and many require no investigation beyond a focused clinical history and examination.

Clinical history

The clinical history is the single most important assessment tool when determining the cause of a headache.

The most significant findings are:

  • Sudden onset – ‘thunderclap’ headache
  • Worst headache ever
  • New headache in the elderly
  • Loss of consciousness
  • Headache associated with activity

If any of these are present, further investigation is required.


The most important features of the clinical examination are:

  • Cognitive state
  • Vital signs
  • Neck movement
  • Eyes – visual fields and eye movements
  • Motor function – pronator drift
  • Gait

If any of these are abnormal, further investigation is required.

However, approximately 10% of patients will have signs or symptoms of headache due to a secondary cause.

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