Get MRI with contrast if you need to get imaging for HA.
“Red flag signs and symptoms include focal neurologic signs, papilledema, neck stiffness, an immunocompromised state, sudden onset of the worst headache in the patient’s life, personality changes, headache after trauma, and headache that is worse with exercise.”
SNOOP: Red Flags for Headache
| Stands for | DDx | Tests to consider | |
| S | Systemic s/s with HA (Fever, rash, fatigue, weight loss, neck stiffness, personality changes | Arteritis, CVD, encephalitis, inflammation, meningitis | Blood tests, LP, neuroimaging, skin biopsy |
| –Secondary risk factors: New HA in pt with HIV, cancer, immunocompromised state, Lyme disease, trauma (HA after trauma) | -CA: Metastasis -HIV: Opportunistic infection; tumor -Lyme: Meningoencephalitis |
LP, Neuroimaging | |
| N | Neurologic signs/symptoms: HA with AMS / ALOC, change in personality, focal neurologic deficits (not typical aura) | CNS infection / Encephalitis; mass lesion; stroke; AVM; CVD; intracerebral bleed, | Blood tests, LP, neuroimaging |
| O | Onset is sudden/abrupt: Sudden onset of the worst HA in the patient’s life. Maximal intensity occurs within seconds to minutes, thunderclap HA |
Bleeding into AVM, mass lesion (esp. posterior fossa), Subarachnoid hemorrhage; | LP, neuroimaging |
| O | Older than 50 yo: New HA after age 50 | Temporal arteritis, Mass lesion Tenderness over temporal artery indicates temporal arteritis, PMR |
ESR, temporal artery biopsy, neuroimaging |
| P | Positional HA changes upright vs lying | HA 2/2 spontaneous Intracranial hypotension; Cervicogenic HA; herniation of a posterior fossa arachnoid cyst; posterior fossa pathology; | Neuroimaging |
| Prior HA now different in quality or progressive/ worsening | Hx of med overuse, mass lesion, subdural hematoma | Neuroimaging | |
| Papilledema: Visual problems | Encephalitis, mass lesion, meningitis, pseudotumor cerebri | LP, neuroimaging |
SNOOP-PAPS is an alternative.
A postural headache (worse in the upright position) is the hallmark of spontaneous intracranial hypotension.
Idiopathic intracranial hypertension (benign intracranial hypertension, pseudotumor cerebri) is characterized by increased pressure within the skull (intracranial pressure).
HA=Headache; CA= Cancer, AVM = Arteriovenous malformation; LP = Lumbar puncture; PMR = Polymyalgia rheumatica; CVD = Collagen vascular disease
AMS: Altered Mental Status; ALOC: Altered level of consciousness
I learned the SNOOP mnemonic from neurologist Dr. Padram Navab in California. It covers the red flags listed in the following AAFP articles.
More Red Flag Signs and Symptoms in the Evaluation of Acute Headache (From AAFP 2013)
| DANGER SIGN OR SYMPTOM | POSSIBLE DIAGNOSES | TESTS | |
|---|---|---|---|
|
First or worst headache of the patient’s life |
Central nervous system infection, intracranial hemorrhage |
Neuroimaging |
|
|
Headache triggered by cough or exertion, or while engaged in sexual intercourse |
Mass lesion, subarachnoid hemorrhage |
Lumbar puncture, neuroimaging |
|
|
New onset of severe headache in pregnancy or postpartum |
Cortical vein/cranial sinus thrombosis, carotid artery dissection, pituitary apoplexy |
Neuroimaging |
|
|
Rapid onset with strenuous exercise |
Carotid artery dissection, intracranial bleed |
Neuroimaging |
|
http://www.aafp.org/afp/2013/0515/p682.html
http://www.aafp.org/afp/2001/0215/p685.html
https://www.ncbi.nlm.nih.gov/m/pubmed/18272121/ – A differential diagnosis in postural headache: herniation of a giant posterior fossa arachnoid cyst. Lu KC, et al. Am J Emerg Med. 2008.