What is the appropriate management for headaches with red flags, such as sudden severe headache, fever, confusion, stiff neck, weakness, numbness, or seizures?

Management of Headaches with Red Flags

Headaches with red flags require immediate medical attention and evaluation to rule out life-threatening conditions. 1, 2

Red Flags Requiring Urgent Evaluation

• Sudden severe headache ("thunderclap" or "worst headache of life") - suggests possible subarachnoid hemorrhage 1, 2
• Fever and neck stiffness - indicates possible meningitis or subarachnoid hemorrhage 1, 2
• Focal neurological deficits (weakness, numbness, visual changes) - suggests stroke, mass lesion, or other intracranial pathology 1, 3
• Altered mental status or confusion - indicates increased intracranial pressure or infection 2, 4
• Headache awakening patient from sleep - suggests increased intracranial pressure 1, 3
• Headache worsened by Valsalva maneuver (coughing, sneezing, exercise) - suggests increased intracranial pressure 1, 2
• New headache onset after age 50 - suggests temporal arteritis or secondary causes 2, 5
• Progressive headache that worsens over time - suggests mass lesion 1, 2
• Headache following head trauma - suggests intracranial injury 1, 2
• Seizures with headache - suggests structural brain abnormality 4, 6

Diagnostic Approach

Immediate Evaluation

• For thunderclap headache or severe acute headache:
  • If presenting <6 hours from onset: Non-contrast head CT interpreted by a neuroradiologist 1
  • If presenting >6 hours from onset or with neurological deficit: Non-contrast head CT followed by lumbar puncture if CT is negative 1, 5

Ottawa SAH Rule

For alert patients >15 years with new severe non-traumatic headache reaching maximum intensity within 1 hour, investigate for subarachnoid hemorrhage if any criteria are met:

• Age ≥40 years
• Neck pain or stiffness
• Witnessed loss of consciousness
• Onset during exertion
• Thunderclap headache
• Limited neck flexion on examination 1

Neuroimaging Selection

• MRI is preferred over CT for most headache evaluations due to higher resolution and absence of radiation exposure 2, 5
• CT without contrast is recommended when acute intracranial hemorrhage is suspected 1, 5

Management Based on Etiology

Suspected Subarachnoid Hemorrhage

• Immediate neurosurgical consultation 4
• Blood pressure control if elevated 7
• Nimodipine to prevent vasospasm if hemorrhage confirmed 7

Suspected Meningitis

• Immediate empiric antibiotics (after blood cultures if possible) 7
• Dexamethasone consideration before or with first antibiotic dose 7
• Lumbar puncture for CSF analysis (after neuroimaging if increased ICP suspected) 7

Suspected Stroke

• Acute stroke protocol activation 2
• Evaluation for thrombolysis eligibility if within time window 2
• For hemorrhagic stroke: neurosurgical consultation and blood pressure management 7

Suspected Mass Lesion

• Neurosurgical consultation 5
• Dexamethasone if significant edema or mass effect 7
• Anti-seizure medication if seizures present 7

Common Pitfalls to Avoid

• Failing to recognize red flags in patients presenting with headache 8, 6
• Attributing new headache to migraine without excluding secondary causes 8, 6
• Delaying neuroimaging when red flags are present 5, 6
• Incomplete neurological examination that might miss subtle focal deficits 3, 6
• Performing lumbar puncture before neuroimaging when increased intracranial pressure is suspected 7, 5

Follow-up

• Close monitoring for patients with concerning features even if initial imaging is negative 4
• Repeat imaging if symptoms persist or worsen despite normal initial studies 5
• Specialist referral for patients with persistent symptoms or uncertain diagnosis 3