Headache cases on CCS test one critical skill: can you distinguish the benign from the life-threatening? The vast majority of headaches in clinical practice are primary (migraine, tension-type, cluster), but CCS cases often include secondary headaches that can kill the patient if missed. Your job is to efficiently screen for red flags, rule out emergencies, and manage appropriately.
Red Flags: The "SNOOP" Mnemonic
Before anything else, screen every headache patient for red flags. If any are present, the case is no longer a simple headache — it is a potential emergency.
• S — Systemic symptoms (fever, weight loss, cancer history, HIV/immunocompromised)
• N — Neurological deficits (focal weakness, visual changes, speech difficulty, altered consciousness)
• O — Onset sudden/thunderclap ("worst headache of my life" = SAH until proven otherwise)
• O — Onset after age 50 (new headache in older patient = temporal arteritis, mass, subdural)
• P — Pattern change (headache different from usual, progressively worsening)
The First 60 Seconds by Setting
ER Headache
Immediate orders:
1. Vital signs (check for hypertensive emergency — SBP > 180 or DBP > 120)
2. Focused neurological exam (pupils, strength, sensation, cerebellar signs, mental status)
3. Fingerstick glucose
4. Pain management — do not withhold (ketorolac IV or acetaminophen IV)
If any red flags: CT head without contrast — STAT
If thunderclap headache: CT head without contrast — STAT. If CT is negative for hemorrhage, proceed to lumbar puncture (rule out SAH with xanthochromia or elevated RBCs).
Clinic Headache
Opening orders:
1. Complete physical exam including neurological exam
2. Review medication list (medication overuse headache is common)
3. Screen for depression (headache and depression frequently coexist)
If no red flags: Diagnose primary headache type and treat.
If red flags present: Send to ER for urgent imaging.
> Study Tip: Headache is one of the most deceptive CCS presentations — it can be a simple migraine or a subarachnoid hemorrhage. The StudyCCS question bank includes both straightforward and "trap" headache cases that test whether you screen for red flags before treating symptoms. Practicing these cases builds the reflex to always check for danger first.
Branch Points by Diagnosis
Branch 1: Thunderclap Headache → Subarachnoid Hemorrhage (SAH)
Workup:
• CT head without contrast — STAT (sensitivity >95% within 6 hours of onset)
• If CT negative → lumbar puncture (look for xanthochromia, elevated RBCs that do not clear between tubes)
• If LP positive → CT angiography (identify aneurysm source)
• Neurosurgery consult — STAT
Management:
• ICU admission
• Nimodipine (prevents vasospasm)
• Blood pressure management
• Seizure prophylaxis (levetiracetam)
• Strict bed rest, stool softeners (prevent rebleed from straining)
• Surgical clipping or endovascular coiling of aneurysm
Branch 2: Fever + Headache + Neck Stiffness → Meningitis
• CT head → lumbar puncture → empiric antibiotics (vancomycin + ceftriaxone + dexamethasone)
• Do NOT delay antibiotics if LP will be delayed
• See detailed meningitis protocol in CCS Fever & Sepsis article
Branch 3: Focal Deficits + Headache → Stroke or Mass Lesion
• CT head without contrast — STAT (rule out hemorrhage)
• If hemorrhagic stroke → neurosurgery consult, BP management, ICU
• If ischemic stroke → CT angiography, consider tPA, neurology consult
• If mass lesion → MRI brain with contrast, neurosurgery/oncology consult, dexamethasone for edema
Branch 4: Headache + Papilledema or Visual Changes → Increased Intracranial Pressure
Consider:
• Idiopathic intracranial hypertension (pseudotumor cerebri) — young obese female
• Brain tumor
• Cerebral venous sinus thrombosis
Workup: CT head → MRI/MRV → lumbar puncture with opening pressure measurement
Branch 5: New Headache in Patient >50 → Temporal Arteritis
Workup:
• ESR and CRP (markedly elevated)
• Temporal artery biopsy (definitive)
• Start prednisone IMMEDIATELY (do not wait for biopsy — prevents blindness)
• Ophthalmology consult
Branch 6: Severe Hypertension + Headache → Hypertensive Emergency
• If SBP > 180 and/or DBP > 120 with end-organ damage (headache, AMS, chest pain, visual changes)
• IV antihypertensive (labetalol or nicardipine)
• Goal: reduce MAP by 25% in first hour
• CT head to rule out hemorrhagic stroke
• Monitoring: serial vitals, neuro checks
• ICU admission
Branch 7: No Red Flags → Primary Headache
Migraine:
• Acute treatment: sumatriptan (if no cardiovascular contraindications), or ketorolac + metoclopramide
• Prophylaxis (if frequent): propranolol, topiramate, or amitriptyline
• Lifestyle counseling: trigger avoidance, sleep hygiene, stress management
• Follow-up in 4–6 weeks
Tension-type headache:
• Acute: acetaminophen or NSAIDs
• Prophylaxis (if chronic): amitriptyline
• Stress management counseling
Cluster headache:
• Acute: high-flow oxygen (100% via non-rebreather), sumatriptan injection
• Prophylaxis: verapamil
• Neurology referral
Don't-Miss Diagnoses
1. Subarachnoid hemorrhage — "Worst headache of my life" + sudden onset. CT head then LP.
2. Bacterial meningitis — Fever + headache + neck stiffness. Start antibiotics immediately.
3. Temporal arteritis — New headache in patient >50 + elevated ESR. Start steroids before biopsy.
4. Hypertensive emergency — Severely elevated BP + headache. Treat BP, rule out stroke.
5. Carbon monoxide poisoning — Headache in multiple household members. Check carboxyhemoglobin.
6. Cerebral venous sinus thrombosis — Headache + focal deficits in young woman on OCPs. MRV.
The Complete Order Set: Headache (ER)
Immediate:
• Vital signs (BP critical), focused neuro exam
• Pain management (ketorolac IV, acetaminophen IV)
• Fingerstick glucose
If red flags present:
• CT head without contrast — STAT
• CBC, BMP, ESR/CRP (if >50 years old), coagulation panel
• LP (if CT negative and SAH or meningitis suspected)
• CT angiography (if SAH confirmed or stroke suspected)
If no red flags:
• Migraine cocktail: ketorolac + metoclopramide + diphenhydramine
• Sumatriptan (if migraine and no cardiovascular risk)
• Reassess in 1–2 hours
Disposition:
• ICU for SAH, hemorrhagic stroke, meningitis
• Floor for observation of complex cases
• Discharge for primary headaches with adequate pain control
• Neurology referral for new or complex headaches
• Follow-up in 1–2 weeks
• Headache diary counseling
2-Minute Screen:
• Follow-up appointment
• Migraine prophylaxis prescription if frequent
• Preventive care screenings
• Smoking cessation, exercise counseling
• Depression screening (PHQ-9)
Want to practice headache cases before exam day? The StudyCCS question bank includes headache presentations ranging from simple migraines to SAH — with real-time scoring that shows you exactly where the algorithm awards and deducts points.
Related Articles:
• CCS Altered Mental Status: First 60 Seconds to Disposition
• CCS Fever & Sepsis: Rapid Workup, Orders & Escalation
• CCS Approach by Chief Complaint: ER vs Clinic vs Floor
• Ultimate Guide to CCS Section of Step 3 (2026)