What are the red flags for headache?

From the Guidelines

Red flags for headaches include sudden onset of severe headache, headaches that worsen with exertion or position changes, new headaches in patients over 50 years old, and headaches accompanied by fever, neck stiffness, or rash, as these may indicate a serious underlying condition requiring immediate medical attention. When evaluating patients with headaches, it is essential to consider these red flags, which may suggest a more severe condition, such as meningitis, brain hemorrhage, tumor, or increased intracranial pressure 1. Some key red flags to look out for include:

• Sudden onset of severe headache, often described as a "thunderclap" headache
• Headaches that worsen with exertion or position changes
• New headaches in patients over 50 years old
• Headaches accompanied by fever, neck stiffness, or rash
• Headaches with neurological symptoms such as weakness, numbness, vision changes, speech difficulties, confusion, or altered consciousness
• Headaches that wake a person from sleep, progressively worsen over days, or don't respond to usual treatments
• Headaches in patients with cancer, HIV, or immunosuppression
• Headaches following head trauma
• Headaches associated with seizures or vomiting without nausea These red flags may indicate serious conditions that require prompt diagnosis and treatment, and immediate medical evaluation is necessary if any of these symptoms are present 1. In clinical practice, it is crucial to prioritize these red flags and take a thorough history and perform a physical and neurologic examination to determine the underlying cause of the headache and provide appropriate management 1.

From the FDA Drug Label

1. 4 Cerebrovascular Events Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities In a number of cases, it appears possible that the cerebrovascular events were primary, the 5-HT1 agonist having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine when they were not. 5.3 Chest, Throat, Neck, and/or Jaw Pain/Tightness/Pressure Sensations of tightness, pain, pressure, and heaviness in the precordium, throat, neck, and jaw commonly occur after treatment with sumatriptan tablets and are usually non-cardiac in origin. However, perform a cardiac evaluation if these patients are at high cardiac risk 5.6 Medication Overuse Headache Overuse of acute migraine drugs (e.g., ergotamine, triptans, opioids, or combination of these drugs for 10 or more days per month) may lead to exacerbation of headache (medication overuse headache).
2. 7 Serotonin Syndrome Serotonin syndrome may occur with sumatriptan tablets, particularly during co-­administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors [see Drug Interactions (7.4)].
3. 8 Increase in Blood Pressure Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients treated with 5-HT1 agonists, including patients without a history of hypertension.
4. 9 Anaphylactic/Anaphylactoid Reactions Anaphylactic/anaphylactoid reactions have occurred in patients receiving sumatriptan.
5. 10 Seizures Seizures have been reported following administration of sumatriptan.

The red flags for headache are:

• Cerebrovascular events: Cerebral hemorrhage, subarachnoid hemorrhage, and stroke
• Cardiac events: Chest, throat, neck, and/or jaw pain/tightness/pressure, arrhythmias
• Medication overuse headache: Overuse of acute migraine drugs for 10 or more days per month
• Serotonin syndrome: Mental status changes, autonomic instability, neuromuscular aberrations, and/or gastrointestinal symptoms
• Increase in blood pressure: Significant elevation in blood pressure, including hypertensive crisis
• Anaphylactic/anaphylactoid reactions: Anaphylactic reactions to drugs
• Seizures: Seizures have been reported following administration of sumatriptan 2 2.

From the Research

Red Flags for Headache

The following are red flags for headache that may indicate serious underlying pathology:

• Focal neurologic signs 3, 4, 5
• Papilledema 3, 4
• Neck stiffness 3
• Immunocompromised state 3
• Sudden onset of the worst headache in the patient's life 3, 4
• Personality changes 3
• Headache after trauma 3, 4
• Headache that is worse with exercise 3
• Abrupt onset 6, 5
• Age 50 years and older 4, 6
• Presence of cancer or immunosuppression 6
• Provocation by physical activities or postural changes 6
• Increased frequency or severity of headache 4
• New onset of headache with an underlying medical condition 4
• Headache with concomitant systemic illness 4

Evaluation and Management

If any of these red flags are present, a thorough neurologic examination should be performed, and neuroimaging or other testing may be necessary to evaluate the cause of the headache 3, 4, 5. The choice of imaging modality depends on the suspected underlying cause of the headache 3, 4, 5.