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8/17/2025 • 12–18 min read

Headache: Red Flags, SAH Rule-out, and Migraine Plan

Most headaches are benign. The job is to find the dangerous minority quickly, then treat primary headaches effectively without causing medication-overuse. This is a practical, risk-first pathway.

Red Flags (SNOOP)

  • Systemic: fever, weight loss, cancer/HIV, pregnancy/postpartum.
  • Neurologic: focal deficits, confusion, seizures, papilledema.
  • Onset sudden: “thunderclap” (peaks in seconds to 1 minute).
  • Older age: new headache ≥50 years.
  • Pattern change/progressive, precipitated by exertion/Valsalva/sex, positional, post-trauma.
  • Other concerns: anticoagulation/bleeding risk, painful red eye, new jaw claudication, neck pain after minor trauma (dissection).

Thunderclap Headache & SAH Pathway

  1. Immediate non-contrast head CT. High sensitivity in the first hours; earlier imaging improves yield.
  2. If CT negative but suspicion remains (timing, story, exam): perform LP for xanthochromia/RBC clearing or CTA per local protocol. Discuss pros/cons; many systems still prefer CT→LP when >6 hours from onset.
  3. Consider reversible cerebral vasoconstriction syndrome (RCVS) (recurrent thunderclaps, postpartum, vasoactive drugs) and cervical artery dissection (neck pain, Horner’s) → CTA/MRA head/neck.

Other Dangerous Look-Alikes

  • Cerebral venous thrombosis (CVT): OCPs, pregnancy/puerperium, infection, hypercoagulable states; headache ± neuro signs; diagnose with MRV/CTV.
  • Giant cell arteritis (GCA): age ≥50, new temporal headache, jaw claudication, scalp tenderness, visual symptoms; check ESR/CRP; start steroids promptly to protect vision.
  • Meningitis/encephalitis: fever, neck stiffness, altered mentation; blood cultures, empiric antibiotics, LP when safe.
  • Carbon monoxide poisoning: winter/indoor exposure, family cluster of headaches; check CO-Hb, give oxygen.
  • Acute angle-closure glaucoma: severe eye pain, halos, N/V; urgent ophthalmology.
  • Idiopathic intracranial hypertension (IIH): young women, pulsatile tinnitus, visual symptoms, papilledema; neuro-ophthalmology + LP opening pressure.

When to Image Routine Headaches

Typical stable migraine or tension-type headache with a normal neurologic exam generally doesn’t need imaging. Image when red flags are present, exam is abnormal, or pattern is new/progressive.

Acute Migraine Treatment (ED/Clinic/Home)

  • First line: NSAIDs (e.g., ibuprofen, naproxen) or acetaminophen early in the attack.
  • Triptans: sumatriptan, rizatriptan, etc.; avoid in known CAD, uncontrolled HTN, hemiplegic/basilar migraine, or with certain serotonergic combos.
  • Antiemetic adjuncts: metoclopramide or prochlorperazine; add diphenhydramine to limit akathisia if using dopamine antagonists.
  • Gepants/ditans: ubrogepant, rimegepant (CGRP antagonists) or lasmiditan (5-HT1F) for triptan-nonresponders or contraindications.
  • Recurrence prevention: a single dose of dexamethasone (e.g., 8–10 mg) can reduce 24–72 h relapse after ED treatment.
  • Avoid opioids—worse outcomes and risk of chronification.

Medication-Overuse Headache (MOH)

Limit simple analgesics to ≤15 days/month and triptans/combination analgesics to ≤10 days/month. Escalate to preventives if frequency creeps up to avoid MOH.

Prevention & Follow-up

  • When: ≥4 headache days/month, disabling attacks, or MOH risk.
  • Options: beta-blockers (propranolol, metoprolol), topiramate, amitriptyline, venlafaxine, valproate (avoid in pregnancy), CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab), onabotulinumtoxinA for chronic migraine (≥15 d/mo).
  • Lifestyle: regular sleep, hydration, exercise, stress strategies; consider magnesium, riboflavin, and CoQ10 evidence-based supplements.
  • Tools: headache diary, trigger review (menstrual pattern, alcohol, MSG/nitrates, sleep loss), return/call precautions.

Patient FAQs

“Do I need a scan?” Not if your exam is normal and the pattern is typical for migraine. Scans are reserved for red flags or new/progressive patterns.

“Are triptans safe?” For most healthy patients, yes. They’re avoided with certain heart/vascular conditions—your clinician screens for this.

References & Notes

Practical risk-first approach: use SNOOP red flags, CT→LP/CTA for thunderclap as indicated, consider key mimics, and treat migraine with non-opioid, stepwise therapy while preventing medication-overuse. Local protocols vary—follow institutional guidance. Educational only.

Educational only, not personal medical advice.