“Red Flags” in the Diagnostic Process

  • Maurice B. Vincent
Reference work entry


Most headaches are primary and do not indicate the presence of underlying diseases. There are cases, however, in which head pain is a symptom of a life-threatening disorder. The physician must recognize red flags that indicate the presence of such serious conditions as they require immediate treatment. Potential seriousness indications include recent, particularly intense and very sudden headaches; pain that either are new after the age of 50 or have substantially changed from the previous head pain patterns; headaches that are concomitant with neurological deficits; headache with papilledema, loss of consciousness, seizures or cognitive impairments, meningeal irritation, or other abnormal neurological signs. Neuroimaging is the most important investigation in headache practice, followed by CSF and blood examinations. Imaging must be performed when red flags are present, and further tests such as spinal taps are required when neuroimaging is not elucidative. Venous thrombosis and the reversible cerebral vasoconstriction syndrome are examples of overlooked disorders that frequently present with headache only and require magnetic resonance venography (MRV) and arteriography for a proper diagnosis. Subarachnoid hemorrhage secondary to intracranial aneurysm, cerebral venous thrombosis, idiopathic thunderclap headache, meningitis, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, acute sinus disease, pituitary apoplexy, primary intracranial hypotension, hydrocephalus, and intracranial occupying lesions are all diseases that may present with headache as the most important or unique symptom.


Trigeminal Neuralgia Giant Cell Arteritis Posterior Reversible Encephalopathy Syndrome Cerebral Venous Thrombosis Intracranial Hypotension 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Ahmed M, Martinez A, Cahill D, Chong K, Whitehouse WP (2010) When to image neurologically normal children with headaches: development of a decision rule. Acta Paediatr 99(6):940–943PubMedCrossRefGoogle Scholar
  2. American College of Emergency Physicians (2002) Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med 39:108–122CrossRefGoogle Scholar
  3. Bennetto L, Patel NK, Fuller G (2007) Trigeminal neuralgia and its management. BMJ 334:201–205PubMedCrossRefGoogle Scholar
  4. Cantini F, Niccoli L, Nannini C, Bertoni M, Salvarani C (2008) Diagnosis and treatment of giant cell arteritis. Drugs Aging 25:281–297PubMedCrossRefGoogle Scholar
  5. Clinch CR (2001) Evaluation of acute headaches in adults. Am Fam Physician 63:685–692PubMedGoogle Scholar
  6. Costa RM, Dumitrascu OM, Gordon LK (2009) Orbital myositis: diagnosis and management. Curr Allergy Asthma Rep 9:316–323PubMedCrossRefGoogle Scholar
  7. Cutrer FM, Boes CJ (2004) Cough, exertional, and sex headaches. Neurol Clin 22:133–149PubMedCrossRefGoogle Scholar
  8. Demaerschalk B, Dodick DW (2003) Recognizing sentinel headache as a premonitory symptom in patients with aneurysmal subarachnoid haemorrhage. Cephalalgia 23:933–934PubMedCrossRefGoogle Scholar
  9. Dhopesh V, Anwar R, Herring C (1979) A retrospective assessment of emergency department patients with complaint of headache. Headache 19:37–42PubMedCrossRefGoogle Scholar
  10. Dodick DW (2002) Thunderclap headache. J Neurol Neurosurg Psychiatry 72:6–11PubMedCrossRefGoogle Scholar
  11. Dodick DW (2004) Indomethacin-responsive headache syndromes. Curr Pain Headache Rep 8:19–26PubMedCrossRefGoogle Scholar
  12. Ducros A, Boukobza M, Porcher R, Sarov M, Valade D, Bousser MG (2007) The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 130:3091–3101, EnglandPubMedCrossRefGoogle Scholar
  13. Edlow JA, Caplan LR (2000) Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 342:29–36PubMedCrossRefGoogle Scholar
  14. Evans RW, Rolak LA (2004) The Alice in Wonderland syndrome. Headache 44:624–625PubMedCrossRefGoogle Scholar
  15. Hildebrand J, Aoun M (2003) Chronic meningitis: still a diagnostic challenge. J Neurol 250:653–660PubMedCrossRefGoogle Scholar
  16. Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin MS, Lamy C, Mas JL, Caplan LR (1996) A reversible posterior leukoencephalopathy syndrome. N Engl J Med 334:494–500PubMedCrossRefGoogle Scholar
  17. Ito M, Adachi N, Nakamura F, Koyama T, Okamura T, Kato M, Kanemoto K, Nakano T, Matsuura M, Hara S (2004) Characteristics of postictal headache in patients with partial epilepsy. Cephalalgia 24:23–28PubMedCrossRefGoogle Scholar
  18. Jakobsson KE, Saveland H, Hillman J, Edner G, Zygmunt S, Brandt L, Pellettieri L (1996) Warning leak and management outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 85:995–999PubMedCrossRefGoogle Scholar
  19. Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL (1990) The international cooperative study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 73:18–36PubMedCrossRefGoogle Scholar
  20. Kernick DP, Ahmed F, Bahra A, Dowson A, Elrington G, Fontebasso M, Giffin NJ, Lipscombe S, MacGregor A, Peatfield R, Weatherby S, Whitmarsh T, Goadsby PJ (2008) Imaging patients with suspected brain tumour: guidance for primary care. Br J Gen Pract 58:880–885PubMedCrossRefGoogle Scholar
  21. Latchaw RE, Silva P, Falcone SF (1997) The role of CT following aneurysmal rupture. Neuroimaging Clin N Am 7:693–708PubMedGoogle Scholar
  22. Leibowitz HM (2000) The red eye. N Engl J Med 343:345–351PubMedCrossRefGoogle Scholar
  23. Leniger T, Isbruch K, von den Driesch S, Diener HC, Hufnagel A (2001) Seizure-associated headache in epilepsy. Epilepsia 42:1176–1179PubMedCrossRefGoogle Scholar
  24. Linn FH, Wijdicks EF, van der Graaf Y, Weerdesteyn-van Vliet FA, Bartelds AI, van Gijn J (1994) Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet 344:590–593PubMedCrossRefGoogle Scholar
  25. Linn FH, Rinkel GJ, Algra A, van Gijn J (1998) Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 65:791–793PubMedCrossRefGoogle Scholar
  26. Linn FH, Rinkel GJ, Algra A, van Gijn J (2000) The notion of “warning leaks” in subarachnoid haemorrhage: are such patients in fact admitted with a rebleed? J Neurol Neurosurg Psychiatry 68:332–336PubMedCrossRefGoogle Scholar
  27. Lippman CW (1952) Certain hallucinations peculiar to migraine. J Nerv Ment Dis 116(4):346–351PubMedCrossRefGoogle Scholar
  28. Marshall SA, Kathuria S, Nyquist P, Gandhi D (2010) Noninvasive imaging techniques in the diagnosis and management of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 21:305–323PubMedCrossRefGoogle Scholar
  29. Martin TJ, Yeatts RP (2000) Abnormalities of eyelid position and function. Semin Neurol 20:31–42PubMedCrossRefGoogle Scholar
  30. Masuhr F, Mehraein S, Einhaupl K (2004) Cerebral venous and sinus thrombosis. J Neurol 251:11–23PubMedCrossRefGoogle Scholar
  31. May A (2009) Morphing voxels: the hype around structural imaging of headache patients. Brain 132:1419–1425, EnglandPubMedCrossRefGoogle Scholar
  32. Morgenstern LB, Luna-Gonzales H, Huber JC Jr, Wong SS, Uthman MO, Gurian JH, Castillo PR, Shaw SG, Frankowski RF, Grotta JC (1998) Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 32:297–304PubMedGoogle Scholar
  33. Negoro K, Morimatsu M, Ikuta N, Nogaki H (2000) Benign hot bath-related headache. Headache 40:173–175PubMedCrossRefGoogle Scholar
  34. Obeliene D, Bovim G, Schrader H, Surkiene D, Mickeviàiene D, Miseviàiene I, Sand T (1998) Headache after whiplash: a historical cohort study outside the medico-legal context. Cephalalgia 18:559–564CrossRefGoogle Scholar
  35. Pascual J, Iglesias F, Oterino A, Vazquez-Barquero A, Berciano J (1996) Cough, exertional, and sexual headaches: an analysis of 72 benign and symptomatic cases. Neurology 46:1520–1524, EUAPubMedGoogle Scholar
  36. Piccioli M, Parisi P, Tisei P, Villa MP, Buttinelli C, Kasteleijn-Nolst Trenite DG (2009) Ictal headache and visual sensitivity. Cephalalgia 29:194–203PubMedCrossRefGoogle Scholar
  37. Podoll K, Robinson D (2000) Illusory splitting as visual aura symptom in migraine. Cephalalgia 20:228–232PubMedCrossRefGoogle Scholar
  38. Podoll K, Robinson D (2001) Recurrent Lilliputian hallucinations as visual aura symptom in migraine. Cephalalgia 21:990–992PubMedCrossRefGoogle Scholar
  39. Sances G, Guaschino E, Perucca P, Allena M, Ghiotto N, Manni R (2009) Migralepsy: a call for a revision of the definition. Epilepsia 50:2487–2496PubMedCrossRefGoogle Scholar
  40. Schievink WI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:898–906PubMedCrossRefGoogle Scholar
  41. Schievink WI (2006) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Am Med Assoc 295:2286–2296CrossRefGoogle Scholar
  42. Schwedt TJ, Dodick DW (2009) Advanced neuroimaging of migraine. Lancet Neurol 8:560–568PubMedCrossRefGoogle Scholar
  43. Scrivani SJ, Mathews ES, Maciewicz RJ (2005) Trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:527–538PubMedCrossRefGoogle Scholar
  44. Smitherman TA, Baskin SM (2008) Headache secondary to psychiatric disorders. Curr Pain Headache Rep 12:305–310PubMedCrossRefGoogle Scholar
  45. Sobri M, Lamont AC, Alias NA, Win MN (2003) Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol 76:532–535CrossRefGoogle Scholar
  46. Valentinis L, Tuniz F, Valent F, Mucchiut M, Little D, Skrap M, Bergonzi P, Zanchin G (2010) Headache attributed to intracranial tumours: a prospective cohort study. Cephalalgia 30(4):389–398PubMedGoogle Scholar
  47. Vincent MB (2010) Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash. Curr Pain Headache Rep 14:238–243PubMedCrossRefGoogle Scholar
  48. Wilne SH, Ferris RC, Nathwani A, Kennedy CR (2006) The presenting features of brain tumours: a review of 200 cases. Arch Dis Child 91:502–506PubMedCrossRefGoogle Scholar
  49. Yankovsky AE, Andermann F, Mercho S, Dubeau F, Bernasconi A (2005) Preictal headache in partial epilepsy. Neurology 65:1979–1981, EUAPubMedCrossRefGoogle Scholar

Copyright information

© Lifting The Burden 2011

Authors and Affiliations

  1. 1.Hospital Universitário Clementino Fraga FilhoUniversidade Federal do Rio de JaneiroRio de JaneiroBrazil

Personalised recommendations