II. Interpretation: Red Flags imply serious cause

III. 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 40 to 50 years old and no prior history or Family History of Headaches
    1. Especially Headache onset after age 40-50 years
    2. Mass lesion
    3. Temporal Arteritis
  3. Progressive in frequency or severity
    1. Medication Overuse Headache
    2. CNS mass 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
    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

IV. 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
  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. Provoked by Valsalva Maneuver
    1. Arnold-Chiari Malformation
  12. Multiple patients with Headache
    1. Carbon Monoxide
  13. Pregnancy or immediately post-partum
    1. Venous sinus thrombosis
    2. Carotid Artery dissection
    3. Pituitary apoplexy
    4. Pregnancy Induced Hypertension (Preeclampsia)
  14. Comorbid illness
    1. Cancer (consider brain metastases)
    2. HIV Infection (Opportunistic infection, tumor)
    3. Lyme Disease (Meningoencephalitis)

V. Red Flags: (Mnemonic - SNOOP)

  1. Systemic symptoms or illness
    1. Fever
    2. Altered Level of Consciousness
    3. Anticoagulation
    4. Pregnancy
    5. Cancer
    6. HIV Infection
      1. See Headache in HIV
      2. Especially concerning in new HIV diagnosis, poor control/compliance or associated fever
  2. Neurologic symptoms or signs
    1. Papilledema
    2. Asymmetric Cranial Nerve function
    3. Asymmetric motor function
    4. Abnormal Cerebellar Function
  3. Onset recently or suddenly
  4. Onset after age 40 years
  5. 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
  6. References
    1. Dodick (2003) Adv Stud Med S550-5

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