Red Flags for Headaches

Melanie Jones, PA-C

Some of the most common complaints given by patients are headaches. Before diagnosing the patient with cluster or tension headache or their usual migraine, other causes should be considered. Consequently, A strong provider should ensure that there is not an underlying secondary cause of their patient’s pain. Accordingly, missing a secondary cause of a headache can have dire consequences for your patient. Here we present several red flags for headaches that all medical providers should be aware of to first form a proper differential diagnosis and then a final diagnosis.

Headache red flags and the snnoop10 system

SNNOOP10 Headache Mnemonic

This mnemonic will help you remember the red flags for headaches. Therefore, if you see any of these findings you should perform an adequate workup or send to the Emergency Department if warranted.

S: Systemic symptoms including fever can be caused by a headache from an infection or nonvascular intracranial disorder, carcinoid or pheochromocytoma.

N: A Neoplasm anywhere in the patient’s history can likewise suggest a tumor-based headache. As such, these can be due to neoplasm of the brain or metastasis to the brain. This is also suspected when headaches are worse in the morning.

N: Finding a Neurologic deficit or even a dysfunction on exam, including decreased consciousness, can signal a headache related to vascular disorder, nonvascular intracranial disorder, brain abscess or other infections. Likewise, this has a broad differential.

O: The onset of a headache is very important. A sudden and abrupt headache (most times the worse headache of their life) can signal a subarachnoid hemorrhage, and likewise cranial vascular disorder or cervical vascular disorders.

O: Older age of patients, especially over 50, can possibly be related to giant cell arteritis,
neoplasm, nonvascular intracranial disorder or cranial/cervical vascular disorders.

P10: There are 10 Ps that you need to be aware of when considering red flags for headaches:

The 10 P’s of Headaches

1 A Pattern change or recent onset of headaches can be related to a neoplasm or also to vascular and nonvascular intracranial disorders.

2. Positional headaches can signal intracranial hypotension or even hypertension.

3. Headaches Precipitated by coughing, sneezing or exercise can signal a Chiari Malformation or Posterior fossa malformation. Likewise, other conditions that cause CSF outflow restriction can do the same.

4. Papilledema found on exam can signal intracranial hypertension, neoplasms, or
other nonvascular intracranial disorders

5. Progressive headaches and atypical presentations can signal neoplasms and other
nonvascular intracranial disorders

6. Pregnancy headaches or puerperium (post-partum) headachew can be attributed to a post epidural puncture headache, cranial/cervical vascular disorders, hypertension related disorders such as pre-eclampsia, hypothyroidism, cerebral sinus thrombosis, anemia, and diabetes

7. Painful eye with autonomic features can signal a pathologic cause in the posterior
fossa, pituitary region, cavernous sinus, Tolosa-Hunt Syndrome or even ophthalmic
causes

8. Post-traumatic onset of headache can be due to acute or chronic post-traumatic (post-concussion syndrome), subdural hematoma, epidural hematoma, or other traumatic vascular cause

9. Pathology of the immune system such as HIV can cause opportunistic infections
leading to headaches

10. Painkiller overuse can also cause headaches. Also new drug at onset of headache can
be due to drug incompatibility

Differential Diagnosis

Nonvascular Headache causes

Here’s a breakdown of some the above diagnoses/illnesses that you definitely need to be aware of. Nonvascular intracranial disorders are considered any disorder in the cranial area that is NOT related to the vascular system. They also include increased CSF pressure, decreased CSF pressure, a non-infectious inflammatory intracranial disease, intracranial neoplasm, intrathecal injections, epileptic seizures, and Chiari Malformations. Likewise, Increased cerebrospinal fluid (CSF) pressure can be related to an idiopathic intracranial hypertension (IIH or pseudotumor cerebri), a metabolic cause, a toxic cause or a hormonal cause. Chromosomal disorders or hydrocephalus can also cause Increased CSF pressure.

CSF Pressure Headaches

The most common reasons for seeing increased CSF are usually hydrocephalus or Increased intracranial hypertension. Decreased cerebrospinal fluid (CSF) pressure can be caused by a post-dural puncture headache, CSF fistula headache or spontaneous intracranial hypotension. In fact, you will most likely see post-dural headaches in common practice. These patients have undergone epidurals for delivery, epidural steroid injections or a lumbar puncture and tend to have headaches that are positional. Sitting and standing worsen symptom. Likewise, lying down Improves these symptoms. Also, neurosarcoidosis, aseptic meningitis, and lymphocytic hypophysitis are non-infectious causes of inflammatory intracranial disease.
.

Intracranial neoplasm can be a primary lesion from the brain or a metastasis. You
will also need to look for colloid cyst of the third ventricle, carcinomatous meningitis and or a
pituitary microadenoma/macroadenoma. Intrathecal injections are done for some patients. This could be TPA if there is a large ventricular clot or antibiotics for an infection. Although the purpose for intrathecal injections are to treat a different cause, if they are not done under proper sterile technique you can have other complications.

Seizure and Trauma Headaches

Epileptic seizures can cause ictal and post-ictal headaches. Medication headaches can be due to prescription or non-prescription medications. Some patients may also have withdrawal headaches from caffeine, opioids, estrogen or use of other substances. Cervical and Cranial Vascular Disorders are numerous and some of the most common illnesses that are seen.
Cerebral ischemic events that include a current or past ischemic stroke (cerebral infarction or a recent TIA). Hemorrhages can be traumatic or non-traumatic. These include epidural
hematoma (EDH), subarachnoid hemorrhage (SAH) and subdural hematoma (SDH). Chronic
hemorrhages can last for some patients for many months and they may have headaches that
persist even after the hemorrhage has resolved.

Vascular Malformations

Vascular malformations include cerebral aneurysms, cavernous malformations,
dural AV fistulas, encephalotrigeminal angiomatosis and leptomeningeal angiomatosis.
Cervical carotid and vertebral artery disorders can lead to headaches with facial or
neck pain after a cervical carotid dissection or vertebral artery dissection. Some patients can
experience headaches after a carotid endarterectomy or a carotid/vertebral angioplasty or stent.

Infections in the brain are another area that you will not want to miss. Does the patient
have HIV? Are they an intravenous (IV) drug user? Does the patient have other signs of
infection, recent sinus surgery, recent ophthalmology, recent cranial surgery? If so, you need to order a MRI to look for infectious findings such as an abscess. Infections need to be treated urgently/emergently and likely will be taken to the OR by Neurosurgery on the same day depending on the patient’s exam and imaging. These patients may very well get a ventriculostomy pre-operatively or post-operatively with intrathecal antibiotics in addition to IV antibiotics. If this is caught in time, most patients will have a great recovery.

Summary

Many of the above conditions will never be encountered in a family practice setting, but you need to be aware of them. You may see some of the above in an ER setting, but if you plan to practice in Neurosurgery, Neurology or Neuro ICU care then you will see many of these and possibly many more. You should be able to recognize the difference between a common migraine, tension headache, cluster headache and a red flag headache. Don’t assume that a patient is exaggerating a symptom and miss an important finding. A lot of your differential diagnoses will be dependent on you doing a thorough Neurologic exam and getting a detailed HPI. If you are unsure about a red-flag headache, get imaging to ensure that you aren’t missing anything.

In summary, familiarize yourself with SNNOOP10 and if you can, memorize/learn it so you will not miss something that needs to be referred out to a higher level of care. The above information should be something that you reference if needed, keep nearby, and have an understanding of to avoid missing a red flag headache. Take it upon yourself to do some more in-depth reading to learn about the conditions above and the pathophysiology. You will definitely be able to notice the red flags for headaches the more you read up on these conditions.

Let us help you become a better provider! Get resources for headaches and TON of other commonly references topics at your fingertips. Check out our Clinical Toolkit today.

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