From Headache To Hospital

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Loud noises, intense light or screen exposure, poor posture, interrupted or limited sleep, poor or inconsistent diet, inadequate hydration, and stress can all lead to a common culprit: headache.

For a lot of us, that’s just an average case of the Mondays. The all-too-familiar mid-afternoon throbbing might lead to taking an over-the-counter pain reliever, drinking some water, rubbing temples, breathing deeply, and getting back to work.

But for over three million Americans each year, a headache elicits an emergency response.¹ In fact, headaches account for one to four percent of all emergency room visits—surprisingly, representing the primary presenting complaint.²

So what can be done for a headache? Hospital staff first explore the patient’s symptoms and consider their history to determine whether further diagnostic evaluation (including neuroimaging) is required.

Studies show most headache patients are diagnosed with migraines, which can involve nausea and vomiting; light, odor, and noise sensitivity; lightheadedness; fatigue; brain fog; numbness; or a stiff neck.

The puzzle is getting to the root of these symptoms, as they can overlap with far more serious conditions. Fortunately, less than two percent of headache patients are diagnosed with meningitis, encephalitis, or subarachnoid hemorrhage (stroke), requiring life-critical care.³

Headache vs. stroke call

Receiving a 911 call for a headache is nothing to roll your eyes at, according to Bryon Schultz, IAED Medical Academics & Standards Expert.

“There’s this preconceived notion that a headache is not a prehospital emergency,” Schultz said, “Typically the patient is suffering enough that they are unable to seek medical attention on their own.”

But don’t make a rookie mistake of dismissing other possibilities. “I once arrived on the scene of a headache call and could immediately see this woman was having a stroke,” Schultz said. “She said she felt weak, but her blood pressure was astronomically high, causing us to wonder how she was still communicating at all.”

With severe underlying concerns, where should the Emergency Medical Dispatcher (EMD) turn for a Chief Complaint of severe headache in the Medical Priority Dispatch System^™ (MPDS^®)? Without any other reported symptoms, Protocol 18: Headache is an obvious selection, with built-in curiosity in case other factors are at play.

“Typically when headache is the Chief Complaint, the patient has a pre-diagnosed issue with migraines or cluster headaches,” Schultz said. “But the complaint of ‘headache’ is the belt and suspenders of stroke as well. The EMD should be listening to capture other indicators such as numbness, difficulty speaking, unbalanced movement, etc.”

As stated in the first Axiom, “the most important objective of [Protocol 18] is to determine if the underlying cause of a headache might be a life-threatening but potentially treatable condition such as STROKE, meningitis, or other serious brain condition. Headache, in and of itself, is not a diagnosis but a very general symptom of many other low-acuity problems.”

Data and Determinant Codes

This guidance seems to be reflected well in how Protocol 18 is used. The IAED Data Center shows that in 151,667 calls (across 378 agencies), about 26.26% of headache calls, are coded as a low-acuity 18-A-1, with the patient “breathing normally.”

Yet the next most frequently used codes are 18-C-4, “Sudden onset of severe pain” (26.05%), and 18-C-2, “Abnormal breathing” (20.88%), which would both warrant the higher CHARLIE-level response.

Fortunately, Protocol 18 is designed to mirror Protocol 28: Stroke (CVA)/ Transient Ischemic Attack (TIA) with similar Determinant Codes, so there is no danger of a potential stroke patient receiving less urgent (or lack of specialized) care from Protocol 18.

However, Protocol 28 does collect more details about stroke symptoms and history of stroke in suspected cases. About 42.9% of these calls are assigned a 28-C-1 response, indicating “Not alert,” followed in use by 28-C-4 “Sudden weakness or numbness (one side)” (12.65%) and 28-C-2 “Abnormal breathing” (11.49%).

Both Protocol 18 and 28 indicate the use of the Stroke Diagnostic Tool to gather details similar to the stroke scale responders use upon arrival. The EMD can trust the Stroke Diagnostic Tool to reliably indicate the patient’s condition even in a nonvisual environment.

“When you ask the patient to raise their arms, smile, and try to speak clearly, we can rely on that information to readily assign an appropriate response, notify the hospital, and alert their specialty teams to prepare for that patient’s care more efficiently,” Schultz said.

Another indicator of the patient’s condition is whether they’re able to call 911 for themselves. On Protocol 18, first-party callers comprise about 44.77% of calls, with 46.25% deferring to a second-party caller. On Protocol 28, only about 15.4% are first-party callers, and 70.84% have a second party call on their behalf. Remaining calls are handled by third- and fourth-party callers, including agencies connected to wearable medical alert devices.

However, first-party callers can and do sometimes still report their own stroke symptoms, which is why the Stroke Diagnostic Tool has a first-party interrogation pathway, using a mirror to check for the patient’s abilities. In recent years, the Additional Information “Stroke Symptoms” section has also been modified to include “sudden speech, reading, or writing problems” to capture even minor disruptions in cognitive abilities.

“We give the tools to the EMD by building in the same responses as a safety net between Protocol 18 and 28,” Schultz said. “But, even so, the data shows EMDs are doing a good job of determining when to use each. It’s usually spot-on.”

Stroke considerations

Just as time is brain during a stroke event, knowledge is power. As an EMD, you must be prepared to act with efficiency and accuracy, as the typical stroke patient loses 1.9 million neurons each minute without intervention. To put that in perspective, compared with the normal rate of neuron loss in brain aging, the ischemic brain ages 3.6 years each hour without treatment.⁴

As medical treatments advance, more people are surviving strokes than ever—in part due to greater awareness to seek treatment—but a stroke patient’s resulting limitations can still be significant with a difficult recovery.⁵ The goal has shifted from simply saving a life to preserving a higher quality of life for the patient.

This is an important consideration when recognizing that strokes are also hitting a younger population with greater frequency. Though the majority of stroke cases still occur in older adults, 10–15% of all strokes occur in people 18 to 50 years old, a rise that may be due to increased risk factors of high blood pressure and cholesterol levels, diabetes, tobacco use (vaping), and obesity.⁶

Other factors such as family history, pregnancy, migraine (aura), heart conditions such as atrial fibrillation, certain infections, or even blood type may increase stroke risks in certain populations.

Stroke neurologists indicate heart and brain health are related, and both are affected by other processes in the body, which means a stroke can occur at any age. In fact, risk of stroke in children is greatest in the weeks surrounding their birth.⁷ For the first time, new guidelines from the American Stroke Association now include guidance for treatment of children.⁸

The cause of about a quarter of stroke patients may remain a mystery even after testing and treatment—especially in young patients. “Never underestimate the human body's ability to do what it’s not supposed to do,” Schultz said.

Conclusion

Whether fielding a severe headache or a patient in critical need, your voice on the line is pivotal, particularly in the stroke patient chain of survival.

Though stroke remains the leading cause of serious long-term disability in the United States and the fourth leading cause of death,9 there is hope for rehabilitation. Exciting developments in research and therapy show that the brain can continue to repair itself—even years after a stroke event—creating a future formerly thought impossible for stroke patients on a journey to recovery.

Sources

1. Lucado, J. Paez, K. Elixhauser, A. “Headaches in U.S. Hospitals and Emergency Departments, 2008.” Agency for Healthcare Research and Quality. 2011; May. ncbi.nlm.nih.gov/books/NBK56047 (accessed Feb. 24, 2026).

2. Doretti, A. Shestaritc, I. Ungaro, D. Lee, JI. Lymperopoulos, L. Kokoti, L. Guglielmetti, M. Mitsikostas, DD. Lampl, C. “Headaches in the emergency department—a survey of patients' characteristics, facts and needs.” School of Advanced Studies of the European Headache Federation (EHF-SAS). 2019; Nov 5. pmc.ncbi.nlm.nih.gov/articles/PMC6833179 (accessed Feb. 24, 2026).

3. See note 2.

4. Saver, JL. “Time is brain--quantified.” Stroke. 2006; Jan. pubmed.ncbi.nlm.nih.gov/16339467 (accessed Feb. 24, 2026).

5. Williamson, L. “Stroke hospitalizations rising among younger adults, but deaths falling.” American Heart Association. 2022; May 16. heart.org/en/news/2022/05/16/stroke-hospitalizations-rising-among-younger-adults-but-deaths-falling (accessed Feb. 24, 2026).

6. See note 5.

7. “5 Surprising Facts About Stroke.” Heart and Stroke Foundation of Canada. 2025; June 3. heartandstroke.ca/articles/5-surprising-facts-about-stroke (accessed Feb. 24, 2026).

8. “About Stroke.” American Stroke Association. 2026. stroke.org/en (accessed Feb. 24, 2026).

9. See note 8.