Presented here are cues you can use to structure your thinking about ominous signs in the headache history which should lead you to be suspicious of a secondary headache disorder. A mnemonic, SNOOPP, can be used to review the signs and symptoms which constitute red flags.
S – Systemic signs and symptoms
N – Neurologic symptoms
O – Sudden onset
O – Older (patient or presentation)
P – Progressive
P – Positional change, Precipitators, Papilledema
S stands for Systemic signs and symptoms
These signs might include weight loss, fever, chills, myalgia, and anorexia.
Systemic signs may occur secondary to medical conditions such as human immunodeficiency virus (HIV), cancer, vasculitides, infections (for example septic or aseptic meningitis and early encephalitis), and cerebrovascular disorders which may present with a headache.
N stands for Neurologic symptoms
This might include focal changes such as reflex abnormalities, weakness, alterations of consciousness, confusion, or cranial nerve deficits.
We need to be alert for possible structural abnormalities such as stroke or tumor or disc derangement in the brain or upper spinal cord which could influence the exam and provoke headaches.
We should also consider bone tumors, metastatic cancer, and carcinomatosis.
O stands for Onset
Was the headache gradual or sudden in onset?
In the case of a sudden onset headache, we must watch out for the most serious cause: a hemorrhage. A thunderclap headache also presents with a sudden onset.
The second O stands for Older
This refers not only to the patient’s age but also the headache circumstance.
First, is the patient over age 50 with a new headache? This might be giant cell arteritis or glaucoma.
Is this current headache a new presentation of headache (a change in their usual headache)? Or is it an old or typical headache circumstance for this person?
P stands for Progressive
We compare this current patient presentation to previous headaches to determine if it is getting worse.
The second P refers to P word characteristics
Does a positional change induce the headache? This is something we see with cerebrospinal fluid leak and resulting intracranial hypotension.
Precipitators such as a Valsalva maneuver or certain activities such as bending or jumping sometimes indicate increased intracranial pressure.
Papilledema is a significant finding in increased intracranial pressure.
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- Chou, DE. 2018. Secondary headache syndromes. Continuum (Minneap Minn). 24: 1179–1191. PMID: 30074555
- Ferguson, LW and Gerwin, R. 2005. Clinical Mastery in the Treatment of Myofascial Pain. Baltimore: Lippincott Williams & Wilkins.
- Fernández-de-las-Peñas, C, Arendt-Nielsen, L, and Gerwin, R. 2010. Tension-Type and Cervicogenic Headache—Pathophysiology, Diagnosis and Management. Sudbury: Jones and Bartlett Publishers.
- Goadsby, PJ and Silberstein, SD. 1997. Headache. Boston: Butterworth-Heinemann.
- Goadsby, PJ, Silberstein, SD, and Dodick, DW. 2005. Chronic Daily Headache for Clinicians. Hamilton: BC Decker.
- Green, MW. 2012. Secondary headaches. Continuum (Minneap Minn). 18: 783–795. PMID: 22868541
- Silberstein, SD, Lipton, RB, and Goadsby, PJ. 2002. Headache in Clinical Practice. 2nd edition. London: Martin Dunitz.