Red and orange flags for secondary headaches in clinical practice
SNNOOP10 list
Abstract
A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.
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Publication history
Received by Neurology April 15, 2018. Accepted in final form August 27, 2018.
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© 2018 American Academy of Neurology.
Publication History
Received: April 15, 2018
Accepted: August 27, 2018
Published online: December 26, 2018
Published in print: January 15, 2019
Disclosure
T. Do, A. Remmers, H. Schytz, C. Schankin, and S. Nelson report no disclosures relevant to the manuscript. M. Obermann has received scientific support, travel support, and/or honoraria from Biogen Idec, Novartis, Sanofi/Genzyme, Pfizer, Teva, Lilly, Schwarz, and Heel; and received research grants from Allergan, Electrocore, Heel, and the German Ministry for Education and Research (BMBF). J. Hansen, A. Sinclair, A. Gantenbein, and G. Schoonman report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.
Study Funding
Thien Phu Do was funded by a grant from Candys Foundation. Christoph Schankin was funded by grants from German Migraine and Headache Society, Eye on Vision Foundation, and Baasch-Medicus-Stiftung.
Authors
Author Contributions
T.P. Do: drafting the original manuscript. A. Remmers: drafting the original manuscript. S. Henrik Winther: conceptualization and revising the manuscript for intellectual content. C. Schankin: conceptualization and revising the manuscript for intellectual content. S.E. Nelson: conceptualization and revising the manuscript for intellectual content. M. Obermann: conceptualization and revising the manuscript for intellectual content. J. Møller Hansen: conceptualization and revising the manuscript for intellectual content. A.J. Sinclair: conceptualization and revising the manuscript for intellectual content. A.R. Gantenbein: conceptualization and revising the manuscript for intellectual content. G.G. Schoonman: conceptualization and revising the manuscript for intellectual content.
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The article by Do et al.1 on secondary headaches is particularly relevant since headache misdiagnosis consistently remains among the most common diagnostic errors in neurology.2 However, the literature must be carefully scrutinized to avoid distorting the use of red flags and, thereby, perpetuating headache mismanagement. For example, Do et al. cited the Birmingham Study describing significant intracranial abnormalities in 2.1% of 530 patients as partial evidence for advancing flags.3 But the Birmingham Study—characterized by limited demographics, patient selection variability, and suboptimal imaging—excluded patients with abnormal imaging arbitrarily labeled insignificant, including, for example, small arachnoid cysts, despite there being no correlations between preoperative cyst volume and headache, or between postoperative reduction and clinical improvement.4 Moreover, Johnston et al.5 noted the study was “rendered meaningless by the lack of follow up to determine whether the [85.5% of] patients not imaged were subsequently found to have an intracranial abnormality.”
Neuroimaging protocols should be prudently refined through well-designed prospective studies focused on improving patient care, recognizing that a reduction of imaging through additional flags may not translate to decreased healthcare expenditure considering the enormous costs associated with headache misdiagnosis, including unnecessary medical expenses, loss of patient productivity, liability expenses, and related factors balanced against an MRI fee.5
References
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For disclosures, please contact the editorial office at [email protected].