Age over 50 years Advanced age increases the risk of temporal arteritis and a mass lesion. Fever or rash A recent history of infection increases the risk for arteritis, collagen vascular disease, encephalitis, or meningitis. Onset of headache related to a fall that involved hitting the head A fall increases the risk of intracranial bleed, especially if the client is on blood thinners. Self-Assessment Quiz Question #14 An important part of medical screening is a review of the patient’s medications. Several medications can increase the possibility of an intracranial bleed as a source of headache pain. These medications include: a. Antibiotics and NSAIDs. b. Antibiotics and anticoagulants. c. NSAIDs, anticoagulants, and glucosteroids. d. NSAIDs, antibiotics, and glucosteroids. ● Change in personality, mental status, or level of consciousness that accompanies the headache and that may indicate a central nervous system infection, an intracerebral bleed, or a mass lesion. ● Tenderness over the temporal artery , which may indicate polymyalgia rheumatica or temporal arteritis. ● Contusion or lacerations on the face or scalp , which may indicate trauma to the head with resultant cranial bleed. Self-Assessment Quiz Question #15 Tenderness over the temporal artery as a source of headache may be an indication of two different headache red flag diagnoses. These include:
glucocorticoids. Medication use can also help you understand a client’s medical history, enabling you to link the medications they are taking to the underlying condition they are being used to treat. HIV history As mentioned above, HIV increases the risk of infection and tumors. In this case, headache might be the product of a central nervous system infection or an intracranial tumor. Recent infection As mentioned above, a coexisting infection in the lungs, sinuses, or orbital areas may precede and cause a central nervous system infection. Pregnancy or postpartum As mentioned above, pregnancy increases the risk of cortical vein/sinus thrombosis, carotid artery dissection, and pituitary apoplexy. History of cancer Metastasis should be considered whenever there is a history of cancer. Metastasis to the brain could be a source of headache pain. History of Lyme disease Lyme disease increases the risk meningoencephalitis. Clinical presentation/physical examination and headaches Specific clinical symptoms and physical examination findings can be considered headache red flags. When present, these symptoms might warrant referral to a medical specialist (Hainer et al., 2013). ● Neurologic abnormalities , particularly in association with acute headache, can be a red flag; these symptoms include unilateral vision loss, meningismus (a group of symptoms similar to meningitis, including headache, reaction to light, and stiff neck (Meningismus – Definition, n.d.), extensor plantar response, and unilateral pronator drift. ● Severe high blood pressure with a systolic pressure greater than 180 mm Hg or diastolic greater than 120 mm Hg; this may signal a central nervous system infection and/or increased intracranial pressure. ● The presence of papilledema , with symptoms involving brief changes to vision such as blurring, double vision, seeing flashes, or vision loss that last a few seconds; this may signal the presence of encephalitis, mass lesion, meningitis, or pseudotumor. Headache pain pattern During the interview at the initial evaluation, it is important to ascertain very specific details about the nature of the patient’s headache. This includes asking about the onset of headaches; if the headaches are constant or intermittent; and if intermittent, how frequently the headaches are present and what makes them worse or better. Outlined below are some specific details about the connection between headache pain pattern and potential red flags: ● Sudden onset of headache pain with maximal intensity occurring within seconds to minutes, which is called a thunderclap headache ; these headaches require immediate attention and are most often seen in the emergency department; this pain pattern can indicate bleeding into Summary In summary, here is a concise list of headache red flags related to medical history, clinical presentation, and pain pattern. Summary headache red flags: Medical history ● History of cancer, HIV, or Lyme disease. ● Illicit drug use. ● Use of certain medications. ● Trauma to the head (fall, motor vehicle crash). ● Pregnant or postpartum. ● Recent fever.
a. Polymyalgia rheumatica and temporal arteritis. b. Rheumatoid arthritis and temporal arteritis. c. Temporal arteritis and polymyalgia rheumatica. d. Intracranial bleed and papilledema.
a mass or arteriovenous malformation, mass lesion, or subarachnoid hemorrhage. ● A description by the patient of the headache being the first or worst headache of their life, which may indicate a central nervous system infection or an intracranial hemorrhage. ● Headache that is triggered by coughing or with exertion or while engaged in sexual intercourse, which may indicate a mass lesion or subarachnoid hemorrhage. ● Rapid onset of headaches with strenuous exercise , which may indicate carotid artery dissection or intracranial bleed. ● Worsening pattern of headache which may indicate a history of medication overuse or the presence of a mass lesion or subdural hematoma.
● Age over 50 years. ● Accompanying rash or fever. Summary headache red flags: Clinical presentation
● Neurologic abnormalities. ● Very high blood pressure. ● Vision changes.
● Personality or mental status changes. ● Tenderness over the temporal artery. ● Facial contusion or laceration.
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Book Code: PTNY1024
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