Headaches are a common presenting complaint in primary care, but while most headaches are benign, some can indicate serious underlying conditions that require immediate attention. Identifying “red flags” in patients presenting with headaches is crucial for primary care health professionals to make timely decisions regarding further investigation or referral. This blog will outline key headache red flags to help guide clinical assessment and ensure serious causes of headaches are not missed.
1. Sudden Onset: Thunderclap Headaches
A headache that reaches maximum intensity within seconds is a major red flag, often referred to as a “thunderclap headache.” This presentation can suggest subarachnoid haemorrhage, particularly if accompanied by neck stiffness, photophobia, or altered consciousness. Thunderclap headaches require urgent investigation, including neuroimaging and possibly lumbar puncture, to rule out life-threatening causes like aneurysmal rupture.
2. New-Onset Headache in Patients Over 50
New or worsening headaches in patients over the age of 50, especially when persistent or associated with scalp tenderness or visual disturbances, should raise concern for giant cell arteritis (GCA). GCA is a vasculitis that affects the temporal arteries and can lead to permanent vision loss if untreated. An elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can support this diagnosis, but early initiation of corticosteroids is often critical even before laboratory confirmation.
3. Headaches with Focal Neurological Symptoms
A headache accompanied by focal neurological symptoms such as unilateral weakness, speech difficulties, visual changes, or altered sensation suggests a possible underlying neurological condition, such as a stroke or brain tumour. These symptoms require urgent imaging, especially if the onset is abrupt or progressive.
Migraines can sometimes be accompanied by transient neurological symptoms (aura), but any atypical or prolonged symptoms, or those occurring for the first time, warrant immediate evaluation to rule out more serious causes.
4. Headache Associated with Fever and Neck Stiffness
Headache combined with fever, neck stiffness, or photophobia is a potential sign of meningitis. Meningitis can be bacterial or viral, with bacterial meningitis requiring urgent antibiotic treatment to prevent serious complications or death. Lumbar puncture is necessary for diagnosis, but antibiotic therapy should not be delayed in cases where bacterial meningitis is strongly suspected.
Additionally, headache with fever in an immunocompromised patient should prompt consideration of opportunistic infections such as fungal meningitis.
5. Headache Post-Trauma
Patients presenting with a headache following head trauma, even weeks after the event, should be evaluated for possible subdural haematoma or other intracranial injury. Symptoms such as confusion, nausea, or neurological deficits can indicate a serious injury, even in the absence of initial loss of consciousness.
6. Headaches with Worsening Frequency or Severity
A headache that progressively worsens in frequency or severity over days or weeks, especially if unresponsive to usual treatments, is concerning for an underlying mass, such as a brain tumour or a venous sinus thrombosis. These patients may report worsening pain in the morning or with Valsalva manoeuvres (e.g., coughing or straining), which increases intracranial pressure.
7. Headaches in Immunocompromised Patients
Patients who are immunocompromised, such as those with HIV, on chemotherapy, or long-term corticosteroids, are at higher risk for infections or malignancies affecting the central nervous system. Headaches in these patients should be carefully evaluated, and even mild symptoms may warrant further investigation, including imaging and lumbar puncture, to rule out opportunistic infections or central nervous system lymphoma.
Conclusion
Recognising headache red flags in primary care is essential for identifying potentially life-threatening conditions early. By paying close attention to the features outlined above, healthcare professionals can ensure timely referrals for investigations and specialist care when necessary.
For further information on headache management, check out Practitioner Development UK’s article on Understanding Different Types of Headaches: A Guide for Primary Care Health Professionals.
References:
Caronna ET, Smetana GW. Diagnostic Evaluation of Headache: An Evidence-Based Approach. BMJ. 2021; 372
Dodick DW, Silberstein SD. Management of Headache and Migraine. The Lancet. 2022; 400(10350):1527-1536.
