Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list

Thien Phu Do, Angelique Remmers, Henrik Winther Schytz, Christoph Schankin, Sarah E. Nelson, Mark Obermann, Jakob Møller Hansen, Alexandra J. Sinclair, Andreas R. Gantenbein, Guus G. Schoonman

Research output: Contribution to journalReview articlepeer-review

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.

Original languageEnglish (US)
Pages (from-to)134-144
Number of pages11
JournalNeurology
Volume92
Issue number3
DOIs
StatePublished - Jan 15 2019

ASJC Scopus subject areas

  • Clinical Neurology

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