Wed Dec 29

When should you go to hospital for a headache? A doctor explains how to tell if it's an emergency

Written by: Natasha Yates, Assistant Professor, General Practice, Bond University

I waited for hours in emergency last night with this dreadful headache, but eventually gave up and left. Should I have kept waiting at the hospital?

This is a surprisingly common scenario I encounter as a general practitioner ^[1]. If you’re wondering how bad your headache needs to be to go to hospital, here’s the advice I give my patients.

Go to hospital now

Let’s start with when you definitely should go to hospital for a bad headache.

Serious and urgent causes of headaches include infection, bleeding, clots and tumours. Don’t hesitate to go straight to hospital (via ambulance, or with a trusted driver) if you notice one or more of the following:

sudden onset of the worst headache you’ve ever had
headache that worsens with exercise or sexual intercourse
neck stiffness (new since the headache started)
high fever that doesn’t lower with over-the-counter pain medication
headache after trauma to your head or neck
personality changes and/or strange behaviour
weakness/numbness on one side of your body.

Three specific situations are also urgent:

pregnant or recently pregnant women who develop a sudden severe headache
people who are immunocompromised (such as someone living with HIV or on strong immune-suppressing medications)
people who’ve had any COVID-19 vaccine in the previous four to 42 days, and who have a persistent headache despite taking simple painkillers ^[2].

If you are reading this and identify with any of the above, stop reading now and go straight to hospital.

For most headaches, don’t go to hospital

Thankfully, most headaches are less serious, and can be managed without a hospital trip. But they can still take a serious toll.

As you read this, 15% of Australians ^[3] are taking painkillers for a headache.

But just because you don’t need to race to hospital doesn’t mean you shouldn’t get help, especially if you’re experiencing regular headaches.

When to see a doctor – and what they’ll ask you

Start by making a long appointment to see a GP to discuss your headache and nothing else. Give it the time and attention it deserves.

It’s helpful to take a record of your headaches for your doctor’s appointment: a “headache diary ^[5]”.

The most important tool doctors have to diagnose headaches is your history ^[6]. You may feel they are asking a lot of questions, but that’s because there are so many possible causes ^[7]. Bear with your GP as they try to get you the most accurate diagnosis.

A doctor sits with a patient, taking notes about his medical history.

Taking a detailed medical history can help. www.shutterstock.com ^[8]

Here are the kinds of questions a doctor may ask, or be asking themselves while they assess you:

Is the pain caused by something straightforward?

Possible common causes include dehydration, eye/neck strain, teeth grinding, lack of sleep or caffeine withdrawal. Even taking regular painkillers can cause “medication overuse” headaches; the cure can become the cause.

Where in your head is the pain?

Sometimes the location of the pain gives a clue. For example, about 35%^[9] of headaches are “tension headaches”, which feel like a tight band around both sides of your head. Another 4% are “cluster headaches”, which start behind one eye (which can go red and watery) and are often associated with a stuffy nose.

Do you have any other symptoms accompanying the headache?

A migraine ^[10] episode may be preceded by an “aura” (such as flashes of light), and often includes symptoms like nausea or vomiting, extreme sensitivity to noise and light, and blurred vision.

Fevers, an altered sense of smell, fatigue and pressure in your ears are features associated with acute sinusitis.

Is there a pattern to your headaches?

Certain headaches, such as migraine episodes or tension headaches, may have triggers that set them off, including certain foods, sleep deprivation, particular smells, or emotional stress.

Hormonal headaches track with menstrual cycles. Once an association is noticed, you may be able to pre-empt and treat headaches early.

Do you have any other medical conditions?

Rarely, very high blood pressure (a hypertensive crisis ^[12]) can cause a headache. However, raised blood pressure during a headache is usually simply your natural response to pain.

It’s essential to have chronic and recurrent headaches diagnosed properly by a doctor. Your GP may send you to another specialist (such as a neurologist or ear, nose and throat surgeon) depending on how complicated your situation appears.

Headaches rarely need diagnostic investigations ^[13], but if your doctor is worried they may organise a CT scan ^[14], MRI scan ^[15] or lumbar puncture ^[16].

Even if you’re sent for further testing, a specific cause may not be found. If that’s the case, your doctor’s goal will be to help you manage your headaches and lessen their impact on your life.

Why migraines are a particular pain

Migraines deserve a special mention here as they can be so debilitating and poorly understood ^[18].

Many people self-diagnose “migraines” incorrectly. But a bad headache is not the same thing as a migraine attack, and some migraine attacks do not even include a headache!

If you think you have migraine attacks, get them diagnosed and treated properly.

Why headaches can be so costly for us all

If you can avoid going to hospital unnecessarily when you have a headache, you’ll benefit yourself and Australia’s health-care system.

Every time you present to an emergency department, it costs you hours of your life, and the community an average of A$561 ^[20].

Seeing your GP is obviously more time-efficient and instead costs the community between A$38 ^[21] to A$75 ^[22].

If headaches interfere with your life, please prioritise your health. See a doctor, get a management plan for them – and save yourself a painfully long wait in emergency.