Headache Red Flag

See Also

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
1. Subarachnoid Hemorrhage
2. CNS Infection (Meningitis, Encephalitis, Brain Abscess)
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
Progressive in frequency or severity
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
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)
Provocative factors (suggestive of mass lesion, Subarachnoid Hemorrhage)
1. Exertional Headache (worse with exertion or sexual activity)
2. Cough Headache
Other red-flag Headache features
1. Change in Headache pattern
2. Headache awakens patient from sleep
3. Occipital or frontal focal Headache

Findings
Associated

Vomiting, Persistent and Progressive
1. CNS mass lesion
Persistent Constitutional Symptoms
1. Consider Temporal Arteritis, Collagen Vascular Disease, Encephalitis, Meningitis
2. Findings
  1. Chronic malaise, myalgias or Arthralgias
  2. Rash
Meningeal signs (neck stiffness, meningismus) and fever
1. Meningitis
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
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
Papilledema (Increased Intracranial Pressure)
1. Encephalitis
2. CNS Mass lesion
3. Meningitis
4. Pseudotumor Cerebri
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
Focal tenderness over temporal artery, Jaw Claudication or proximal myalgias
1. Temporal Arteritis
Seizure history
Headache occurring after Head Trauma
1. Intracranial Hemorrhage (e.g. Epidural Hematoma, Subdural Hematoma)
Precipitated or provoked by valsalva (e.g. sneezing, coughing) or Exercise
1. Posterior fossa CNS Lesion (e.g. Arnold-Chiari Malformation)
2. Subarachnoid Hemorrhage
Positional Headache
1. Intracranial Hypertension
2. Intracranial Hypotension
Multiple patients with Headache
1. Carbon Monoxide
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
Comorbid illness
1. Cancer (consider brain metastases)
2. HIV Infection (Opportunistic infection, tumor)
3. Lyme Disease (Meningoencephalitis)

Findings
(Mnemonic - SNNOOP10)

Duplicates many of the causes listed above
Systemic symptoms or illness
1. Fever
2. Altered Level of Consciousness
3. Anticoagulation
4. Pregnancy
5. Lyme Disease
Neurologic symptoms or signs
1. Papilledema
2. Asymmetric Cranial Nerve function
3. Asymmetric motor function
4. Abnormal Cerebellar Function
Neoplasm History
1. 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)
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
References
1. 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]
Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]