II. Interpretation: Red Flags imply serious cause
III. Findings: Headache, Severe and incapacitating
- First or worst Headache of patient's life
- Age over 40 to 50 years old and no prior history or Family History of Headaches
- Especially Headache onset after age 40-50 years
- Mass lesion
- Temporal Arteritis
- Progressive in frequency or severity
- Medication Overuse Headache
- CNS mass lesion
- Subdural Hematoma
- Sudden onset reaching severe, maximal intensity within minutes to under one hour (Thunderclap Headache)
- Subarachnoid Hemorrhage (or other Intracranial Hemorrhage such as from AV malformation)
- Meningitis
- Cerebral venous sinus thrombosis
- Idiopathic Intracranial Hypotension
- Pituitary apoplexy
- CNS mass lesion (especially posterior fossa)
- Vertebral Artery Dissection (or Carotid Artery dissection)
- Hypertensive Emergency
- Acute angle closure Glaucoma
- Reversible cerebral Vasoconstriction syndrome
- Rapid onset with strenuous Exercise
- See Exertional Headache
- Carotid Artery dissection
- Subarachnoid Hemorrhage (or other Intracranial Hemorrhage such as from AV malformation)
- Provocative factors (suggestive of mass lesion, Subarachnoid Hemorrhage)
- Exertional Headache (worse with exertion or sexual activity)
- Cough Headache
- Other red-flag Headache features
IV. Findings: Associated
-
Vomiting, Persistent and Progressive
- CNS mass lesion
- Persistent Constitutional Symptoms
- Consider Temporal Arteritis, Collagen Vascular Disease, Encephalitis, Meningitis
- Findings
- Chronic malaise, myalgias or Arthralgias
- Rash
- Meningeal signs (neck stiffness, meningismus) and fever
- Focal neurologic signs
- Consider AV Malformation, collagen vascular disease, Intracranial Mass lesion
- Findings
- Progressive visual disturbance
- Weakness, clumsiness, or loss of balance
-
Headache with personality change or Altered Level of Consciousness
- CNS Infection (Meningitis, Encephalitis, Brain Abscess)
- Intracerebral bleeding (e.g. Subarachnoid Hemorrhage)
- CNS mass lesion
-
Papilledema (Increased Intracranial Pressure)
- Encephalitis
- CNS Mass lesion
- Meningitis
- Pseudotumor Cerebri
- Eye Pain
- Focal tenderness over temporal artery, Jaw Claudication or proximal myalgias
- Seizure history
- Headache occurring after Head Trauma
- Provoked by Valsalva Maneuver
- Multiple patients with Headache
- Pregnancy or immediately post-partum
- Venous sinus thrombosis
- Carotid Artery dissection
- Pituitary apoplexy
- Pregnancy Induced Hypertension (Preeclampsia)
- Comorbid illness
- Cancer (consider brain metastases)
- HIV Infection (Opportunistic infection, tumor)
- Lyme Disease (Meningoencephalitis)
V. Red Flags: (Mnemonic - SNOOP)
- Systemic symptoms or illness
- Fever
- Altered Level of Consciousness
- Anticoagulation
- Pregnancy
- Cancer
- HIV Infection
- See Headache in HIV
- Especially concerning in new HIV diagnosis, poor control/compliance or associated fever
- Neurologic symptoms or signs
- Papilledema
- Asymmetric Cranial Nerve function
- Asymmetric motor function
- Abnormal Cerebellar Function
- Onset recently or suddenly
- Onset after age 40 years
- Prior Headache History that is different or progressive
- Different location is less useful as predictor of serious cause
- Pain response to standard Headache therapy is not predictive of serious cause
- References
- Dodick (2003) Adv Stud Med S550-5
VI. References
- Edlow and Weinstock (2013) EM:Rap 13(12): 7-8
- Coutin (1996) Am Fam Physician 54(7):2247-52 [PubMed]
- Diamond (1997) Postgrad Med 101(1):169-79 [PubMed]
- Dodlick (1997) Postgrad Med 101(5):46-64 [PubMed]
- Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
- Ramirez -Lassepas (1997) Arch Neurol 54(12): 1506-9 [PubMed]
