Abstract
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.
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References
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):940–943
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 39:108–122
Bennetto L, Patel NK, Fuller G (2007) Trigeminal neuralgia and its management. BMJ 334:201–205
Cantini F, Niccoli L, Nannini C, Bertoni M, Salvarani C (2008) Diagnosis and treatment of giant cell arteritis. Drugs Aging 25:281–297
Clinch CR (2001) Evaluation of acute headaches in adults. Am Fam Physician 63:685–692
Costa RM, Dumitrascu OM, Gordon LK (2009) Orbital myositis: diagnosis and management. Curr Allergy Asthma Rep 9:316–323
Cutrer FM, Boes CJ (2004) Cough, exertional, and sex headaches. Neurol Clin 22:133–149
Demaerschalk B, Dodick DW (2003) Recognizing sentinel headache as a premonitory symptom in patients with aneurysmal subarachnoid haemorrhage. Cephalalgia 23:933–934
Dhopesh V, Anwar R, Herring C (1979) A retrospective assessment of emergency department patients with complaint of headache. Headache 19:37–42
Dodick DW (2002) Thunderclap headache. J Neurol Neurosurg Psychiatry 72:6–11
Dodick DW (2004) Indomethacin-responsive headache syndromes. Curr Pain Headache Rep 8:19–26
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, England
Edlow JA, Caplan LR (2000) Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med 342:29–36
Evans RW, Rolak LA (2004) The Alice in Wonderland syndrome. Headache 44:624–625
Hildebrand J, Aoun M (2003) Chronic meningitis: still a diagnostic challenge. J Neurol 250:653–660
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 334:494–500
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 24:23–28
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 85:995–999
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 73:18–36
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 58:880–885
Latchaw RE, Silva P, Falcone SF (1997) The role of CT following aneurysmal rupture. Neuroimaging Clin N Am 7:693–708
Leibowitz HM (2000) The red eye. N Engl J Med 343:345–351
Leniger T, Isbruch K, von den Driesch S, Diener HC, Hufnagel A (2001) Seizure-associated headache in epilepsy. Epilepsia 42:1176–1179
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 344:590–593
Linn FH, Rinkel GJ, Algra A, van Gijn J (1998) Headache characteristics in subarachnoid haemorrhage and benign thunderclap headache. J Neurol Neurosurg Psychiatry 65:791–793
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 68:332–336
Lippman CW (1952) Certain hallucinations peculiar to migraine. J Nerv Ment Dis 116(4):346–351
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 21:305–323
Martin TJ, Yeatts RP (2000) Abnormalities of eyelid position and function. Semin Neurol 20:31–42
Masuhr F, Mehraein S, Einhaupl K (2004) Cerebral venous and sinus thrombosis. J Neurol 251:11–23
May A (2009) Morphing voxels: the hype around structural imaging of headache patients. Brain 132:1419–1425, England
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 32:297–304
Negoro K, Morimatsu M, Ikuta N, Nogaki H (2000) Benign hot bath-related headache. Headache 40:173–175
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 18:559–564
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, EUA
Piccioli M, Parisi P, Tisei P, Villa MP, Buttinelli C, Kasteleijn-Nolst Trenite DG (2009) Ictal headache and visual sensitivity. Cephalalgia 29:194–203
Podoll K, Robinson D (2000) Illusory splitting as visual aura symptom in migraine. Cephalalgia 20:228–232
Podoll K, Robinson D (2001) Recurrent Lilliputian hallucinations as visual aura symptom in migraine. Cephalalgia 21:990–992
Sances G, Guaschino E, Perucca P, Allena M, Ghiotto N, Manni R (2009) Migralepsy: a call for a revision of the definition. Epilepsia 50:2487–2496
Schievink WI (2001) Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med 344:898–906
Schievink WI (2006) Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. J Am Med Assoc 295:2286–2296
Schwedt TJ, Dodick DW (2009) Advanced neuroimaging of migraine. Lancet Neurol 8:560–568
Scrivani SJ, Mathews ES, Maciewicz RJ (2005) Trigeminal neuralgia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:527–538
Smitherman TA, Baskin SM (2008) Headache secondary to psychiatric disorders. Curr Pain Headache Rep 12:305–310
Sobri M, Lamont AC, Alias NA, Win MN (2003) Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol 76:532–535
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):389–398
Vincent MB (2010) Cervicogenic headache: a review comparison with migraine, tension-type headache, and whiplash. Curr Pain Headache Rep 14:238–243
Wilne SH, Ferris RC, Nathwani A, Kennedy CR (2006) The presenting features of brain tumours: a review of 200 cases. Arch Dis Child 91:502–506
Yankovsky AE, Andermann F, Mercho S, Dubeau F, Bernasconi A (2005) Preictal headache in partial epilepsy. Neurology 65:1979–1981, EUA
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Vincent, M.B. (2011). “Red Flags” in the Diagnostic Process. In: Martelletti, P., Steiner, T.J. (eds) Handbook of Headache. Springer, Milano. https://doi.org/10.1007/978-88-470-1700-9_14
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DOI: https://doi.org/10.1007/978-88-470-1700-9_14
Publisher Name: Springer, Milano
Print ISBN: 978-88-470-1699-6
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