Neurology Book

Headache Disorders

  • Headache Red Flag

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Headache Red Flag

Aka: Headache Red Flag, Thunderclap Headache
  1. See Also
    1. Headache
    2. Organic Headache
  2. Interpretation: Red Flags imply serious Headache cause
    1. See Organic Headache
    2. See Acute Generalized Headache
  3. Findings: Headache, Severe and incapacitating
    1. First or worst Headache of patient's life
      1. Subarachnoid Hemorrhage
      2. CNS Infection (Meningitis, Encephalitis, Brain Abscess)
    2. Age over 50 years old (esp. over age 65 years) and no prior history or Family History of Headaches
      1. CNS Lesion
      2. Temporal Arteritis
    3. Progressive in frequency or severity
      1. Medication Overuse Headache
      2. CNS Lesion
      3. Subdural Hematoma
    4. Sudden onset reaching severe, maximal intensity within minutes to under one hour (Thunderclap Headache)
      1. Subarachnoid Hemorrhage (or other Intracranial Hemorrhage such as from AV Malformation)
      2. Meningitis
      3. Cerebral Venous Sinus Thrombosis (or Cerebral Venous Thrombosis)
      4. Idiopathic Intracranial Hypotension
      5. Pituitary apoplexy
      6. CNS mass lesion (especially posterior fossa)
      7. Vertebral Artery Dissection (or Carotid Artery Dissection)
      8. Hypertensive Emergency
      9. Acute angle closure Glaucoma
      10. Reversible Cerebral Vasoconstriction Syndrome
    5. Rapid onset with strenuous Exercise
      1. See Exertional Headache
      2. Carotid Artery Dissection
      3. Subarachnoid Hemorrhage (or other Intracranial Hemorrhage such as from AV Malformation)
    6. Provocative factors (suggestive of mass lesion, Subarachnoid Hemorrhage)
      1. Exertional Headache (worse with exertion or sexual activity)
      2. Cough Headache
    7. Other red-flag Headache features
      1. Change in Headache pattern
      2. Headache awakens patient from sleep
      3. Occipital or frontal focal Headache
  4. Findings: Associated
    1. Vomiting, Persistent and Progressive
      1. CNS mass lesion
    2. Persistent Constitutional Symptoms
      1. Consider Temporal Arteritis, Collagen Vascular Disease, Encephalitis, Meningitis
      2. Findings
        1. Chronic malaise, myalgias or Arthralgias
        2. Rash
    3. Meningeal signs (neck stiffness, meningismus) and fever
      1. Meningitis
    4. Focal neurologic signs
      1. Consider AV Malformation, Collagen vascular disease, Intracranial Mass lesion
      2. Findings
        1. Progressive visual disturbance
        2. Weakness, clumsiness, or loss of balance
    5. Headache with personality change or Altered Level of Consciousness
      1. CNS Infection (Meningitis, Encephalitis, Brain Abscess)
      2. Intracerebral bleeding (e.g. Subarachnoid Hemorrhage)
      3. CNS mass lesion
    6. Papilledema (Increased Intracranial Pressure)
      1. Encephalitis
      2. CNS Mass lesion
      3. Meningitis
      4. Pseudotumor Cerebri
    7. Eye Pain
      1. Acute Angle-Closure Glaucoma
      2. Temporal Arteritis
      3. Trigeminal Neuralgia
      4. Cluster Headache or other trigeminal autonomic Cephalgia
      5. Posterior fossa or pituitary CNS Lesion
      6. Cavernous Sinus Thrombosis
      7. Tolosa-Hunt Syndrome
    8. Focal tenderness over temporal artery, Jaw Claudication or proximal myalgias
      1. Temporal Arteritis
    9. Seizure history
    10. Headache occurring after Head Trauma
      1. Intracranial Hemorrhage (e.g. Epidural Hematoma, Subdural Hematoma)
    11. Precipitated or provoked by valsalva (e.g. sneezing, coughing) or Exercise
      1. Posterior fossa CNS Lesion (e.g. Arnold-Chiari Malformation)
      2. Subarachnoid Hemorrhage
    12. Positional Headache
      1. Intracranial Hypertension
      2. Intracranial Hypotension
    13. Multiple patients with Headache
      1. Carbon Monoxide
    14. Pregnancy or immediately post-partum
      1. See Headache in Pregnancy
      2. Pregnancy Induced Hypertension (e.g. Preeclampsia)
      3. Cranial or cervical vascular disorder (e.g. Carotid Artery Dissection)
      4. Cerebral Sinus Thrombosis or other Venous sinus thrombosis
      5. Postdural puncture
      6. Hypothyrodism
      7. Anemia
      8. Pituitary apoplexy
    15. Comorbid illness
      1. Cancer (consider brain metastases)
      2. HIV Infection (Opportunistic infection, tumor)
      3. Lyme Disease (Meningoencephalitis)
  5. Findings: (Mnemonic - SNNOOP10)
    1. Duplicates many of the causes listed above
    2. Systemic symptoms or illness
      1. Fever
      2. Altered Level of Consciousness
      3. Anticoagulation
      4. Pregnancy
      5. Lyme Disease
    3. Neurologic symptoms or signs
      1. Papilledema
      2. Asymmetric Cranial Nerve function
      3. Asymmetric motor function
      4. Abnormal Cerebellar Function
    4. Neoplasm History
      1. Brain metastases or Intracranial Tumor
    5. Onset recently or suddenly
    6. Onset after age 50 years (esp. 65 years old)
    7. P10 (ten causes starting with the letter P)
      1. Prior Headache History that is different or progressive
        1. Different location is less useful as predictor of serious cause
        2. Pain response to standard Headache therapy is not predictive of serious cause
      2. Positional Headache
        1. Intracranial Hypertension
        2. Intracranial Hypotension
      3. Precipitated by sneezing, coughing or Exercise
        1. Posterior fossa CNS Lesion (e.g. Arnold-Chiari Malformation)
        2. Subarachnoid Hemorrhage
      4. Progressive Headache
        1. CNS Lesion
      5. Papilledema
        1. Intracranial Hypertension
        2. CNS Lesion
      6. Painful eye (may be with autonomic features)
        1. Acute Angle-Closure Glaucoma
        2. Temporal Arteritis
        3. Trigeminal Neuralgia
        4. Cluster Headache or other trigeminal autonomic Cephalgia
        5. Posterior fossa or pituitary CNS Lesion
        6. Cavernous Sinus Thrombosis
        7. Tolosa-Hunt Syndrome
      7. Pregnancy or Postpartum
        1. See Headache in Pregnancy
        2. Pregnancy Induced Hypertension (e.g. Preeclampsia)
        3. Cranial or cervical vascular disorder (e.g. Carotid Artery Dissection)
        4. Cerebral Sinus Thrombosis or other Venous sinus thrombosis
        5. Postdural puncture
        6. Hypothyrodism
        7. Anemia
        8. Pituitary apoplexy
        9. Posterior Reversible Encephalopathy Syndrome (PRES)
        10. Reversible Cerebral Vasoconstriction Syndrome
      8. Post-Trauma
        1. Subdural Hematoma
      9. Pathology of Immune System
        1. Opportunistic infections (e.g. Brain Abscess)
        2. HIV Infection
          1. See Headache in HIV
          2. Especially concerning in new HIV diagnosis, poor control/compliance or associated fever
      10. Pain killer overuse
        1. Medication Overuse Headache
    8. References
      1. Dodick (2003) Adv Stud Med S550-5
  6. References
    1. Edlow and Weinstock (2013) EM:Rap 13(12): 7-8
    2. Coutin (1996) Am Fam Physician 54(7):2247-52 [PubMed]
    3. Diamond (1997) Postgrad Med 101(1):169-79 [PubMed]
    4. Dodlick (1997) Postgrad Med 101(5):46-64 [PubMed]
    5. Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
    6. Ramirez -Lassepas (1997) Arch Neurol 54(12): 1506-9 [PubMed]
    7. Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]

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