Headache

Any person, 16 years and over, presenting with a headache, excluding suspected stroke (FAST positive).

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Consider auscultation of chest (breath sounds) Oxygen saturations (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	Headache with signs of shock and/or SBP less than 90 mmHg should be considered sepsis until proven otherwise. Switch to sepsis (suspected) protocol

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	If febrile, escalate care as per local CERS protocol Consider meningitis or encephalitis (suspected) protocol
Skin inspection, including posterior surfaces	If non-blanching rash is present, consider meningitis or encephalitis (suspected) protocol or sepsis (suspected) protocol
Neck stiffness	Assess for neck stiffness (may indicate meningitis): Place chin to chest (flexion) Look up to the roof (extension) Look left and right (right and left rotation) Ear to shoulder (right and left lateral flexion) Consider meningitis or encephalitis (suspected) protocol

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete neurological focused assessment.

Precautions and notes

• A careful history and physical assessment, including precipitating factors, remain the most important part of identifying serious risk features for patients presenting with headaches.
• Opioids may alter a neurological assessment.
• Cluster headaches can have similar symptoms to more serious headaches due to their rapid onset. They can be differentiated by their transient nature, lasting a few hours and are often associated with tearing and rhinorrhoea.
• Headaches may be caused by medication overuse. Opioid analgesics, triptans, and ergots are frequently associated. Patients using these medications more than 10 days per month may be at risk.

Interventions and diagnostics

Specific treatment

• Some patients with cluster and migraine headaches can benefit from high-flow oxygen therapy. Start trial at 15 L/min via a non-rebreather, if not contraindicated.
• Consider comfort measures, such as darkened room.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

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Pathology

• FBC, UEC
• Pregnant: urinalysis, check for proteinuria
• Temp less than 35°C, or 38.5°C and over: take two sets of blood cultures from two separate sites
• Potential carboxyhaemoglobin poisoning: ABG (if trained) or VBG to assess for carboxyhaemoglobin (COHb) and lactate
• Warfarinised: INR

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au