Diagnosing and managing non-traumatic headache in the emergency department: A narrative review based on the international classification of headache disorders, 3rd edition, and contemporary evidence-based guidelines

Abstract

Headache is a common reason for presentation to the emergency department (ED), ranging from benign primary headache disorders to life-threatening secondary causes. This narrative, nonsystematic review provides a practical ED-oriented synthesis of the assessment and management of nontraumatic headache using the International Classification of Headache Disorders, 3 ^rd edition (ICHD-3), together with contemporary guideline-based recommendations. We intentionally included both adult and pediatric literature when it informed ED triage, diagnostic workup, or early management. A search was conducted in PubMed/Medline, Scopus, LILACS, and SCIELO for English-language articles from July 2008 to July 2023, with supplementary targeted hand-searching during manuscript revision to identify key guideline documents and major ED-relevant publications published through January 2025. Grey literature sources were reviewed selectively, and priority was given to clinical practice guidelines, systematic reviews, major narrative reviews, and pivotal original studies relevant to emergency care. Literature was reviewed to summarize the epidemiology, clinical classification, diagnostic strategies, and treatment of both primary and secondary headache disorders. Particular attention was given to triage principles, red flags, neuroimaging indications, and syndrome-specific treatment. The review also addresses acute ED management, disposition decisions, and clearly distinguishes ED interventions from specialist-directed therapies and outpatient preventive strategies. By aligning clinical assessment with the ICHD-3 and current therapeutic evidence, this review provides a structured, ED-oriented framework to improve diagnostic accuracy, early management, and safe patient disposition. This review is intended to support ED decision-making and is not a substitute for individualized clinical judgment.