II. Interpretation: Red Flags imply serious Headache cause
III. Findings: Headache, Severe and incapacitating
- First or worst Headache of patient's life
- Age over 50 years old (esp. over age 65 years) and no prior history or Family History of Headaches
- Progressive in frequency or severity
- 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 (or Cerebral Venous 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
- Acute Angle-Closure Glaucoma
- Temporal Arteritis
- Trigeminal Neuralgia
- Cluster Headache or other trigeminal autonomic Cephalgia
- Posterior fossa or pituitary CNS Lesion
- Cavernous Sinus Thrombosis
- Tolosa-Hunt Syndrome
- Focal tenderness over temporal artery, Jaw Claudication or proximal myalgias
- Seizure history
- Headache occurring after Head Trauma
- Precipitated or provoked by valsalva (e.g. sneezing, coughing) or Exercise
- Posterior fossa CNS Lesion (e.g. Arnold-Chiari Malformation)
- Subarachnoid Hemorrhage
- Positional Headache
- Intracranial Hypertension
- Intracranial Hypotension
- Multiple patients with Headache
- Pregnancy or immediately post-partum
- See Headache in Pregnancy
- Pregnancy Induced Hypertension (e.g. Preeclampsia)
- Cranial or cervical vascular disorder (e.g. Carotid Artery Dissection)
- Cerebral Sinus Thrombosis or other Venous sinus thrombosis
- Postdural puncture
- Hypothyrodism
- Anemia
- Pituitary apoplexy
- Comorbid illness
- Cancer (consider brain metastases)
- HIV Infection (Opportunistic infection, tumor)
- Lyme Disease (Meningoencephalitis)
V. Findings: (Mnemonic - SNNOOP10)
- Duplicates many of the causes listed above
- Systemic symptoms or illness
- Neurologic symptoms or signs
- Papilledema
- Asymmetric Cranial Nerve function
- Asymmetric motor function
- Abnormal Cerebellar Function
- Neoplasm History
- Brain metastases or Intracranial Tumor
- Onset recently or suddenly
- Onset after age 50 years (esp. 65 years old)
- P10 (ten causes starting with the letter P)
- 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
- Positional Headache
- Intracranial Hypertension
- Intracranial Hypotension
- Precipitated by sneezing, coughing or Exercise
- Posterior fossa CNS Lesion (e.g. Arnold-Chiari Malformation)
- Subarachnoid Hemorrhage
- Progressive Headache
- Papilledema
- Intracranial Hypertension
- CNS Lesion
- Painful eye (may be with autonomic features)
- Acute Angle-Closure Glaucoma
- Temporal Arteritis
- Trigeminal Neuralgia
- Cluster Headache or other trigeminal autonomic Cephalgia
- Posterior fossa or pituitary CNS Lesion
- Cavernous Sinus Thrombosis
- Tolosa-Hunt Syndrome
- Pregnancy or Postpartum
- See Headache in Pregnancy
- Pregnancy Induced Hypertension (e.g. Preeclampsia)
- Cranial or cervical vascular disorder (e.g. Carotid Artery Dissection)
- Cerebral Sinus Thrombosis or other Venous sinus thrombosis
- Postdural puncture
- Hypothyrodism
- Anemia
- Pituitary apoplexy
- Posterior Reversible Encephalopathy Syndrome (PRES)
- Reversible Cerebral Vasoconstriction Syndrome
- Post-Trauma
- Pathology of Immune System
- Opportunistic infections (e.g. Brain Abscess)
- HIV Infection
- See Headache in HIV
- Especially concerning in new HIV diagnosis, poor control/compliance or associated fever
- Pain killer overuse
- Prior Headache History that is different or progressive
- 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]
- Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]