Phys · neurological
Headache — Systematic Approach
Also known as migraine · tension-type headache · cluster headache · giant cell arteritis · temporal arteritis · idiopathic intracranial hypertension · pseudotumour cerebri · trigeminal neuralgia · medication-overuse headache · thunderclap headache · subarachnoid haemorrhage
Consultant-physician-depth guide to the systematic approach to headache — primary headaches (migraine, tension-type, cluster, trigeminal autonomic cephalalgias), secondary headaches, the SNNOOP10 red-flag screen, giant cell arteritis, idiopathic intracranial hypertension, trigeminal neuralgia, and medication-overuse headache — for FRACP DWE and DCE preparation.
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Target exams
Red flags
- Thunderclap headache — reaching maximum intensity within 1 minute — is subarachnoid haemorrhage until proven otherwise. CT within 6 hours has near-100 per cent sensitivity; after 6 hours, LP for xanthochromia is required.
- New headache in a patient over 50 — consider giant cell arteritis. Untreated, it causes irreversible blindness within hours to days. Check ESR and CRP and start prednisolone 40-60 mg immediately.
- Headache with papilloedema or visual obscurations — consider raised intracranial pressure from idiopathic intracranial hypertension or a mass lesion. Urgent neuroimaging, then LP opening pressure.
- Positional headache (worse on standing or lying flat) suggests intracranial hypotension or a posterior fossa mass respectively.
- Headache precipitated by Valsalva, cough, or exertion suggests a posterior fossa lesion, Chiari malformation, or venous sinus thrombosis.
- Focal neurological deficit with headache — investigate with neuroimaging. Hemiplegic migraine is a diagnosis of exclusion.
- Headache with fever and neck stiffness — bacterial meningitis until proven otherwise; do not delay antibiotics.
- Pregnancy or puerperium with new headache — consider pre-eclampsia, cortical vein thrombosis, or idiopathic intracranial hypertension.
- Painful red eye with halos around lights — acute angle-closure glaucoma; ophthalmic emergency requiring immediate measurement of intraocular pressure.
- Analgesic intake on 15 or more days per month for 3 months — medication-overuse headache. Withdrawal is the treatment.
Headache — Systematic Approach
The one-line answer
Every headache lives or dies on a single fork: is this a benign primary headache, or a dangerous secondary one? Primary headaches — migraine, tension-type, cluster — make up about 90 per cent of presentations and are diagnosed by their characteristic pattern once red flags are excluded. Secondary headaches — subarachnoid haemorrhage, giant cell arteritis, raised pressure, infection, mass lesion — make up the remaining 10 per cent but carry nearly all the morbidity and mortality.[2]
The instrument that splits the fork at the bedside is the SNNOOP10 red-flag screen. Pass every headache through it before you ever commit to a primary label; a single positive item earns neuroimaging or targeted blood tests.[2]
The four emergencies that never forgive a delay: subarachnoid haemorrhage (thunderclap — CT within 6 hours, then LP for xanthochromia), giant cell arteritis (over 50 — draw ESR/CRP then start prednisolone immediately, never waiting for results), bacterial meningitis (fever and neck stiffness — antibiotics before the LP), and acute angle-closure glaucoma (painful red eye with halos — measure the intraocular pressure).[1]
The mantra: SNNOOP10 first, then primary or secondary, then let the pattern fit — never label a thunderclap as migraine.[1]
References11ShowHide
- [1]Headache Classification Committee of the International Headache Society (IHS) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition Cephalalgia, 2018.PMID 29368949
- [2]Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list Neurology, 2019.PMID 30587518
- [3]Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society Neurology, 2012.PMID 22529202
- [4]Goadsby PJ, Reuter U, Hallström Y, et al. A Controlled Trial of Erenumab for Episodic Migraine N Engl J Med, 2017.PMID 29171821
- [5]Silberstein SD, Dodick DW, Bigal ME, et al. Fremanezumab for the Preventive Treatment of Chronic Migraine N Engl J Med, 2017.PMID 29171818
- [6]Cohen AS, Burns B, Goadsby PJ High-flow oxygen for treatment of cluster headache: a randomized trial JAMA, 2009.PMID 19996400
- [7]Perry JJ, Stiell IG, Sivilotti MLA, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache JAMA, 2013.PMID 24065011
- [8]Friedman DI, Liu GT, Digre KB Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children Neurology, 2013.PMID 23966248
- [9]Wall M, McDermott MP, Kieburtz KD, et al. Effect of acetazolamide on visual function in patients with idiopathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension treatment trial JAMA, 2014.PMID 24756514
- [10]Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies Neurology, 2008.PMID 18716236
- [11]Ponte C, Grayson PC, Robson JC, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis Ann Rheum Dis, 2022.PMID 36351706