What is the appropriate management for patients presenting with red flag headache symptoms, including sudden onset severe headache, fever, confusion, or stiff neck?

From the Guidelines

Patients presenting with red flag headache symptoms, including sudden onset severe headache, fever, confusion, or stiff neck, require immediate emergency evaluation to rule out life-threatening conditions, and the management should begin with rapid triage and neuroimaging, typically a non-contrast CT scan of the brain, as recommended by the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1. The clinical presentation of these patients can be variable, but the hallmark of aneurysmal subarachnoid hemorrhage (aSAH) is a sudden and severe headache, often described as the "worst headache of my life" 1. The Ottawa SAH Rule can be used to identify patients who require additional investigation for SAH, including those with age ≥40 years, neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion on examination 1. Key considerations in the management of these patients include:

• Rapid triage and neuroimaging, typically a non-contrast CT scan of the brain
• Lumbar puncture if subarachnoid hemorrhage is suspected and CT is negative
• Empiric antibiotic therapy for suspected bacterial meningitis, with ceftriaxone and vancomycin, and addition of acyclovir if herpes encephalitis is a possibility
• Close monitoring in an intensive care setting with neurological checks, vital signs monitoring, and seizure precautions The urgency of treatment is critical, as delays can significantly increase mortality and neurological sequelae, and these interventions are necessary to prevent complications and improve outcomes in patients with life-threatening conditions such as aSAH and bacterial meningitis 1.

From the Research

Red Flag Headache Symptoms

Red flag headache symptoms are warning signs that may indicate a secondary headache disorder, which can be a serious medical condition. These symptoms include:

• Sudden onset severe headache
• Fever
• Confusion
• Stiff neck
• Systemic symptoms, such as weight loss or fever 2
• Neurologic deficit, including decreased consciousness 2
• Older age (onset after 65 years) 2
• Pattern change or recent onset of new headache 2
• Positional headache 2
• Precipitated by sneezing, coughing, or exercise 2
• Papilledema 2
• Progressive headache and atypical presentations 2
• Pregnancy or puerperium 2
• Painful eye with autonomic features 2
• Posttraumatic onset of headache 2
• Pathology of the immune system, such as HIV 2
• Painkiller overuse or new drug at onset of headache 2

Management of Red Flag Headache Symptoms

Patients presenting with red flag headache symptoms should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. This evaluation should include:

• A careful history with attention to red flag symptoms 3
• A neurologic examination 3
• Imaging studies, such as noncontrast brain computed tomography (CT) 4, 5
• Lumbar puncture, if necessary 4, 5
• Laboratory tests, such as complete blood count and blood chemistry tests 6

Diagnosis of Secondary Headache Disorders

Secondary headache disorders can be caused by a variety of medical conditions, including:

• Subarachnoid hemorrhage 3, 4, 5
• Reversible cerebral vasoconstriction syndrome 3
• Elevated intracranial pressure 3
• Hydrocephalus 3
• Cerebral venous sinus thrombosis 3
• Arterial dissection 3
• Central nervous system infection 3
• Inflammatory vasculitis 3
• Neoplastic disorders 2, 6
• Infectious disorders 2, 6
• Intracranial pressure/volume disorders 6

Treatment of Secondary Headache Disorders

Treatment of secondary headache disorders depends on the underlying medical condition. For example:

• Subarachnoid hemorrhage requires immediate medical attention and may require surgical intervention 4, 5
• Reversible cerebral vasoconstriction syndrome may require treatment with calcium channel blockers or other medications 3
• Elevated intracranial pressure may require treatment with medications or surgical intervention 3
• Hydrocephalus may require treatment with shunting or other surgical procedures 3
• Cerebral venous sinus thrombosis may require treatment with anticoagulation therapy 3
• Arterial dissection may require treatment with anticoagulation therapy or surgical intervention 3
• Central nervous system infection may require treatment with antibiotics or other medications 3
• Inflammatory vasculitis may require treatment with corticosteroids or other medications 3
• Neoplastic disorders may require treatment with surgery, radiation therapy, or chemotherapy 2, 6
• Infectious disorders may require treatment with antibiotics or other medications 2, 6
• Intracranial pressure/volume disorders may require treatment with medications or surgical intervention 6