Treatment with epidural steroid injections in the lower spine is not effective for reducing pain and disability. The injections may be more effective than placebo at short-term follow-up, but the effects are not clinically meaningful..

Patients with a headache and red flags (acute thunderclap headache, fever with meningeal irritation on physical examination, papilledema with focal neurologic signs or impaired consciousness, concern for acute glaucoma) in their history or physical examination warrant further investigation for secondary causes of headache. Consider giant cell arteritis in patients older than 50 years who present with a new or evolving headache. Patients with acute thunderclap headache should be sent to the emergency department and should receive computed tomography of the head within 12 hours of symptom onset. Lumbar puncture must follow a normal computed tomography scan to exclude subarachnoid hemorrhage. Patients with stable primary headache disorders (i.e., no red flags and a normal neurologic examination) do not need neuroimaging. .

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