Red and orange flags for secondary headaches in clinical practice

Abstract

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort

“…A finding of concern is that 76% of patients underwent examinations that exposed them to radiation. These should only be prescribed by the practitioner in the case of ‘red flags' or atypical phenotypes in clinical practice and it is unlikely that this was the case in such a high proportion of our participants . Some studies highlight that even in paediatric patients the use of CT scan to diagnose headache remains high despite existing guidelines .…”

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“…Additional technical investigations may be required guided by elements from history or clinical examination, and evaluations by fellow specialists (eg, neurosurgeons, ophthalmologists, psychiatrists, etc) may follow . 41 …”

Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline

“…50 These signs and symptoms guide neuroimaging selections such as ordering angiography for suspected reversible cerebral vasoconstriction syndrome, or gadolinium enhancement for suspected low pressure headache. Subjects with concerning clinical or exam features frequently have abnormalities which require attention and should be imaged.…”

“…While criteria have been promoted to guide recognition of secondary headache, so called "red flags" such as fever, immunosuppression, papilledema, or pregnancy, especially in combination increase the chances of secondary headache. 50 These signs and symptoms guide neuroimaging selections such as ordering angiography for suspected reversible cerebral vasoconstriction syndrome, or gadolinium enhancement for suspected low pressure headache.…”