Dangerous Headaches

DANGEROUS HEADACHE

Headaches which are dangerous

Not all headaches are dangerous. We must know which headaches are dangerous and which are not. These dangerous signals, signs, and symptoms are called red flags of headaches disorders. Let us see who are these!

RED FLAGS OF HEADACHE

In our day-to-day practice, we encounter a lot of patients complaining of headaches. The most common types are tension-type headache, migraine (with or without aura), medication overuse headache, and cluster headache. Headache can present with certain features that needs urgent evaluation. These features are termed as Red Flags. Neurology National and Regional guidelines had formulated pneumonic SNOOP in 2003 which has been updated to

 

 SNNOOP10  in 2019. We will discuss below.

 

S Systemic features including fever  –  Systemic symptoms included are photophobia, phonophobia, nausea, vomiting, altered consciousness, nuchal rigidity, and seizures.

DD- Bacterial meningitis -2-5 yrs – Hemophilus influenzae

Older children – Neisseria meningitides

>40 years – Streptococcus pneumoniae

Brain abscess – Headache with drowsiness, confusion, focal neurological deficits, seizures

Viral and bacterial encephalitis

HIV

Lyme disease

Fungal and protozoal infections Nonvascular intracranial disorder Pheochromocytoma

Carcinoid syndrome

N Neoplasm  in  history – Headache – Bilateral, dull, aching, and rarely throbbing, worse on the side ipsilateral to a tumor and increases ICP from Valsvalva’s maneuver and exertion accompanied by nausea and vomiting

DD – Infratentorial tumors more common

Pituitary tumor Craniopharyngioma CP angle tumor

Metastasis – Lung cancer, Breast cancer, Malignant Melanoma

N Neurologic  deficit  /dysfunction (including decreased consciousness)

DD – Headaches related to vascular, non-vascular intracranial disorders, brain abscess,es and other infections.

Migraine with aura

Ischemic Stroke (posterior cerebral circulation is commonly involved)

O Onset  of  Headache  is  sudden  /abrupt

DD- Subarachnoid hemorrhage – ruptured Berry aneurysm – Bilateral headache becomes severe in a very brief interval, transient loss of consciousness, bleeding, nausea, vomiting, meningismus, focal neurologic symptoms, seizures

Arteriovenous malformation

O Older  age  (after  50  years)

DD -Tension-type  Headache, Migraine

Giant cell arteritis – Headache is throbbing and continuous, more on chewing, focally worse in the temporal region and localized to scalp vessels,  associated with weight loss, night sweats, low-grade fever, jaw claudication, and aching of joints

Polyarteritis nodosa Kawasaki disease Wegener’s granulomatosis Microscopic polyarteritis Churg Strauss syndrome

P Pattern  changes/recent  onset

DD – Neoplasms

Headaches attributed to vascular, non-vascular intracranial disorders

P Positional  Headache

DD – Idiopathic Intracranial hypertension – Pseudotumor cerebri/benign

 

intracranial hypertension – Headache with transient episodes of visual loss, diplopia from 6th cranial nerve palsies, papilloedema, pulse synchronous stimuli, nausea, and neck stiffness.

 

Intracranial hypotension

P Precipitated  by  sneezing, coughing, or  exercise

DD – Primary Cough Headache

         Primary exertional  headache

         Posterior fossa malformation

Chiari malformation

P Papilloedema

DD – Glaucoma

 

          Neoplasms

 

Nonvascular intracranial disorder

Intracranial hypertension

P  Progressive  headache  and  atypical  presentation  DD – Neoplasm

Nonvascular intracranial disorder

P Pregnancy  /  Puerperium

DD – Postdural Puncture Headache

Hypertension related disorders(Eg. Preeclampsia) Cerebral sinus thrombosis

Hypothyroidism

Anemia

Diabetes

P Painful  eye  with  autonomic  features

DD – Posterior cranial fossa tumors Tolosa Hunt syndrome Cavernous sinus thrombosis

Ophthalmic causes-Trigeminal Autonomic Cephalalgia

P The post-traumatic onset  of  Headache

DD- Acute and chronic post-traumatic headache

Subdural hematoma

  1. P   Pathology  of the immune  system   –  HIV
  2. P  Painkiller  overuse  /  new  medicine  used  for  treatment

DD- Medication overuse headache

References:

Diagnosis, assessment, and management of headache-Manuela Fonteasso

Diagnosing headache – American  Society of  Neurology. Neurology volume  92, Number 3

Pain management – Waldman 2 nd edition

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