Patients with headache represent a common diagnostic and treatment challenge for health care providers in the emergency department. The therapeutic options continue to grow, yet many studies imply that narcotics continue to be a frequently chosen treatment. In this retrospective cross-sectional survey, the evaluation and treatment patterns of patients presenting to an academic medical center emergency department with a primary diagnosis of headache were analyzed. Headache disorders accounted for 1.7% of all visits to the emergency department. Migraine headache was the most common headache diagnosis representing 60% of headache visits followed by headache of no obvious source at 25%. Narcotics were the most common treatment employed (180 patient-visits) in all patients and non-steroidal anti-inflammatory agents were the second most common agent used (86 patient visits). Narcotics were also the most common therapy in migraine headache patients (152 patient-visits) while ergotamines were used in less than one-third of patient-visits (36 patient-visits). Therapy of headache patients in the emergency department continues to rely on narcotics. Methods of interrupting the dependence on narcotics need to be explored if newer non-narcotic therapies are to be successful.