This study explores the claim that headache management can be improved by evaluating current emergent care. A retrospective chart review investigated primary complaints of headache during a three-month period. Two hundred and twenty seven patients were identified for review and three-month follow-up using fully available records and imaging. A total of 543/8,759 had a neurological condition. The most common conditions were headaches (42% or 227 cases), cerebrovascular problems (26%) and seizures (17%). No 'usual headache' patterns showed abnormal imaging. In contrast, those with 'sudden-onset' type or clinical findings had an abnormal scan 17% of the time. Of the MRIs ordered, one-quarter changed management. On discharge, 39% of patients left without a specific headache diagnosis. In the discussion, we evaluate how well a tertiary referral ED treats its most common neurological complaint, focusing on the controversial topics of when to investigate and prevention of re-attendance.