Exam
Headache Red Flag
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Headache Red Flag
, Thunderclap Headache
Interpretation
Red Flags imply serious
Headache
cause
See
Organic Headache
See
Acute Generalized Headache
Findings
Headache
, Severe and incapacitating
First or worst
Headache
of patient's life
Subarachnoid Hemorrhage
CNS Infection
(
Meningitis
,
Encephalitis
,
Brain Abscess
)
Age over 40 to 50 years old and no prior history or
Family History
of
Headache
s
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 (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
Change in
Headache
pattern
Headache
awakens patient from sleep
Occipital or frontal focal
Headache
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
Arthralgia
s
Rash
Meningeal signs (neck stiffness, meningismus) and fever
Meningitis
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
Focal tenderness over temporal artery,
Jaw Claudication
or proximal myalgias
Temporal Arteritis
Seizure
history
Headache
occurring after
Head Trauma
Intracranial Hemorrhage
(e.g.
Epidural Hematoma
,
Subdural Hematoma
)
Provoked by
Valsalva Maneuver
Arnold-Chiari Malformation
Multiple patients with
Headache
Carbon Monoxide
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)
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
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]
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