From the Guidelines
Red flags for secondary headache syndrome include sudden onset of severe headache, headaches that begin after age 50, progressively worsening headaches, and headaches accompanied by neurological symptoms, as identified in the most recent study 1. These red flags suggest potentially serious underlying causes such as subarachnoid hemorrhage, brain tumor, meningitis, encephalitis, cerebral venous thrombosis, or other structural or systemic conditions. The red flags can be categorized into two main groups: those related to patient history and those related to physical examination. Some key red flags in the patient history include:
- Thunderclap headache, which may indicate subarachnoid haemorrhage 1
- Atypical aura, which may suggest transient ischaemic attack, stroke, epilepsy, or arteriovenous malformations 1
- Head trauma, which may indicate subdural haematoma 1
- Progressive headache, which may suggest an intracranial space-occupying lesion 1
- Headache aggravated by postures or manoeuvres that raise intracranial pressure, which may indicate intracranial hypertension or hypotension 1 In the physical examination, red flags include:
- Unexplained fever, which may suggest meningitis 1
- Neck stiffness, which may indicate meningitis or subarachnoid haemorrhage 1
- Focal neurological symptoms, which may suggest a secondary headache 1
- Weight loss, which may suggest a secondary headache 1
- Impaired memory and/or altered consciousness or personality, which may also suggest a secondary headache 1 It is essential to note that these red flags are indications for further investigation, such as neuroimaging, blood samples, or lumbar puncture, as suggested by the study 1. Prompt medical evaluation is crucial when these red flags are present, as some causes of secondary headache can be life-threatening and require immediate intervention. Diagnostic workup may include neuroimaging, lumbar puncture, or other tests depending on the suspected underlying cause, as recommended by the study 1. Secondary headaches differ from primary headaches because they result from another medical condition rather than being the condition itself. The study 1 provides a comprehensive overview of the red flags associated with secondary headaches, highlighting the importance of prompt medical evaluation and further investigation when these red flags are present. In clinical practice, it is crucial to prioritize the patient's safety and well-being by promptly evaluating and investigating secondary headaches, as suggested by the study 1. By doing so, healthcare professionals can provide timely and effective treatment, improving patient outcomes and reducing the risk of morbidity and mortality. The study 1 emphasizes the importance of a thorough patient history and physical examination in identifying red flags for secondary headache syndrome. Healthcare professionals should be vigilant in recognizing these red flags and take prompt action to investigate and treat the underlying cause, as recommended by the study 1.
From the Research
Red Flags for Secondary Headache Syndrome
The following are red flags that may indicate a secondary headache syndrome:
- Systemic symptoms, including fever 2
- Neoplasm history 2
- Neurologic deficit, including decreased consciousness 2
- Sudden or abrupt onset 2, 3, 4
- Older age, onset after 65 years 2
- Pattern change or recent onset of new headache 2, 3
- Positional headache 2
- Precipitated by sneezing, coughing, or exercise 2, 3
- Papilledema 2
- Progressive headache and atypical presentations 2
- Pregnancy or puerperium 2
- Painful eye with autonomic features 2
- Posttraumatic onset of headache 2, 5
- Pathology of the immune system, such as HIV 2
- Painkiller overuse or new drug at onset of headache 2
- Focal neurological signs or seizure 3
- High pain intensity 3
- Systemic signs 3
- Precipitation by physical activity 3
Clinical Features and Diagnosis
A thorough history and physical examination, along with a comprehensive differential diagnosis, may alert a physician to the diagnosis of a secondary headache 4, 5, 6. Evaluation and workup include a complete neurological examination, consideration of neuroimaging, and serum/spinal fluid analysis if indicated 4. Careful attention to the patient's history and physical examination will guide the diagnostic work-up and management 4.