Headache in the emergency department: Sex differences in triage, diagnostic evaluation, and treatment.

Abstract

AimHeadache is a common neurological complaint in emergency departments (EDs). However, potential sex-related differences in triage assessment, diagnostic evaluation, and management remain poorly understood. This study examined sex differences across the emergency care pathway among patients presenting with headache.MethodsWe conducted a cross-sectional observational study of adult patients presenting with headache to a large university hospital ED between 5 May 2023, and 5 May 2025. Sex differences were analyzed across key stages of emergency care, including Manchester Triage System (MTS) assignment, pain intensity, ED process times, diagnostic procedures, acute treatment, and final diagnoses. Multivariable logistic regression models were used to assess associations between sex and clinical management outcomes while adjusting for potential confounders. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated.ResultsAmong 95,150 ED presentations during the study period, 1825 adults (1.9%) presented with headache (61.9% women; mean age 48.5 ± 19.7 years). Women were more frequently assigned higher-urgency triage categories, whereas male sex was associated with lower odds of higher-urgency triage (aOR 0.79, 95% CI 0.62-0.99). Use of cranial CT and lumbar puncture did not differ by sex, while men had lower odds of cranial MRI (aOR 0.48, 95% CI 0.26-0.90). Men were more likely to be diagnosed with secondary headache due to serious pathology (aOR 1.54, 95% CI 1.08-2.19) and less likely with primary headache disorders (aOR 0.73, 95% CI 0.54-0.98). Women more often received repeated non-opioid analgesics (aOR 1.60, 95% CI 1.06-2.44) and antiemetics (aOR 1.69, 95% CI 1.16-2.45). No evidence of systematic sex-based delays in ED care delivery was observed.ConclusionSex differences in emergency headache care emerge early in the clinical pathway. Lower perceived urgency despite a higher likelihood of serious pathology among men suggests a potential mismatch between triage assessment and underlying clinical risk. These findings highlight the need to further evaluate sex-related factors in triage and diagnostic pathways for patients presenting to the ED with headache.