From the Guidelines
Red flags in headaches are warning signs that may indicate a serious underlying condition requiring immediate medical attention, and the most critical ones include sudden onset of severe headache, headache with fever or neck stiffness, and headache after head trauma, as identified in the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1. The presence of these red flags necessitates urgent medical evaluation, typically including neuroimaging (CT or MRI) and possibly lumbar puncture, to rule out life-threatening conditions such as subarachnoid hemorrhage, meningitis, brain tumor, cerebral venous thrombosis, or temporal arteritis. Some key red flags to look out for include:
- Sudden onset of severe headache (thunderclap headache)
- Headache with fever or neck stiffness
- Headache after head trauma
- Headache with neurological symptoms (weakness, numbness, vision changes, speech difficulties)
- Headache that worsens with coughing or exertion
- New headache in patients over 50 years old
- Headache with systemic symptoms (weight loss, night sweats)
- Headache that progressively worsens
- Headache in patients with cancer, HIV, or immunosuppression The Ottawa SAH Rule, as outlined in the 2023 guideline, serves as a method to screen out individuals with a low likelihood of aSAH, and its application can help identify patients who require additional testing 1. It is essential to note that while most headaches are benign, recognizing these red flags allows for timely diagnosis and treatment of potentially serious conditions that could lead to permanent disability or death if left untreated, as emphasized in the diagnosis and management of migraine in ten steps 1.
From the Research
Headache Red Flags
- Headache caused by a subarachnoid hemorrhage (SAH) from a ruptured aneurysm is one of the most deadly, with a median case-fatality of 27-44% 2
- Red flag symptoms that require careful attention include abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes 3, 4
- Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders, and clinicians should have a different threshold to conduct evaluations in such patients 3
- A significant proportion of patients are diagnosed with SAH on lumbar puncture (LP), and it is essential to perform a LP in all cases with clinically suspected SAH with a negative CT 5
Diagnosis and Management
- Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder 4
- Fifth generation CT scanners are probably more sensitive than earlier scanners at detecting SAH, but LP is still essential in cases with clinically suspected SAH and a negative CT 6
- Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine, while preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA 4