Red and Orange Flags for Screening Secondary Headache in Clinical Practice SNOOP 10 list

Introduction: Estimated that 18% of patients with a headache have a secondary headache disorder.A validated screening tool could reduce unneeded neuroimaging, laboratory tests for a suspected secondary headache and is costly and refuse from false positive and incidental findings, furthermore it is not possible to detect every secondary headache with neuroimaging or laboratory test, red flags direct the clinician to initiate work up plan and vice versa the absence of red flags may suggest that no work up is needed.Red flags: Define as symptoms that encourage testing or observation of the patient.Orange flags: Define as information that is only alarming when it occur, with other orange or red flags national and regional guide line for screen of potential causes of headache provide mnemonic SNNOOP 10:1- S-Systemic symptoms/ signs including feverHeadache attributed to infection: concurrent fever and headache has high sensitivity for neuroinfection including bacterial or viral meningitis, encephalitis and brain abscesses. Headache with fever is alarming.2- N- Neoplasm history Brain neoplasm, metastasis3- N- Neurologic deficit including decreased consciousness Causes of neurologic deficits presenting with headache are: migraine with aure, stroke (hemorrhagic or ischemic), infections, abscesses and tumors.4- O- Onset of headache is sudden or abrupt (thunderclap headache= TCH)TCH can be the only initial symptoms of subarachnoid hemorrhage other neurologic conditions that causes, TCH are apoplexy of hypophys, cerebral venous thrombosis, meningitis, carotid dissection.5- O-Old age (onset after 65 years) Headache patients≥ 65 years old have a higher for identifying a secondary alarming etiology like temporal arteritis, stroke, and tumor. 6- P-Pattern change or recent onset of new headache A recent change of pattern or a newly developed headache can be the only signs of a serious underlying etiology. A correct diagnosis is often delayed in these cases.7- P-Positional headache Positional headache is the trademark of intracranial hypotension and the most common cause is CSF leak at the spinal level. 8- P-Precipitated by sneezing- coughing (valsalva) or exercise Cough headache can be a sign of serious underlying pathology such as Chair malformations. Posterior fossa vascular malformation or tumor.9- P-Papilledema A high prevalence of patients with papilledema has a serious underlying pathology (neoplasm, intracranial hypertension). 10- P-Progressive headache and atypical presentation Can be the only signs of serious underlying pathology: like neoplasm and other nonvascular intracranial disorders. 11- P-Pregnancy or puer perium Headache during pregnancy and puer prium has a higher risk of sever pathology due to physiologic changes and intervention in these periods. Other risk factor are absence of headache history, seizures, hypertension, fever and headache occur during third trimester postural puncture, cerebral venous thrombosis, and preeclampsia.12- P-Painful eye with autonomic features Patients with presentations of painful eye with autonomic features it can due to a structural lesion and should undergo neuroimaging. 13- P-Post traumatic onset of headache Post traumatic headache is on unspecific marker depending sociodemographic factors, nonetheless headache related to trauma should always be explored in acute and chronic subdural hematoma, and other vascular disease.14- P-Pathology of immune system such as HIV Headache is the most common pain problem in patients with HIV. The risk of severe pathology like cerebral toxoplasmosis, primary CNS lymphoma and progressive multifocal leukoencephalopathy (PML) dependent on the degree of immune suppression.15- P-Painkiller overuse (MOH) or new drug at onset of headache Medication overuse headache (MOH) is the most common cause of secondary headache onset of headache due to a new drug can be a sign of incompatibility with given drug.Conclusion: With using the systemic SNNOOP 10 list to screen new headache patients will increase of detecting a secondary cause of headache, and using red flags would be a validate screening tool for detecting of secondary headache.

Keywords:

Red flags , Yellow flags , Headache