Headache Red Flags for Primary Care

businessman closes eyes and pinches nose due to headache
businessman closes eyes and pinches nose due to headache
Although most primary headaches can be managed by PCPs, some headaches warrant referral to a specialist.

Typical headaches are often managed effectively by primary care providers. Primary headaches include migraine, tension, and cluster headaches. Secondary headaches may signal a serious underlying disorder, such as neoplasm, meningitis, hemorrhage, infection, or giant cell arteritis, among other conditions. Secondary headaches can also be caused by medication overuse or exposure to or withdrawal from certain substances.1,2

“The overwhelming majority of headaches in primary care are primary headaches . . . Secondary headaches are the red flags that primary care providers need to look for,” says Lawrence C. Newman, MD, professor of neurology and director of The Headache Institute at the Mount Sinai Health System in New York City.

Diagnosing Headaches

Most headaches can be diagnosed clinically with a thorough history and physical examination. A screening neurological examination is also essential.1,2 “My neurological exam for all headaches includes [assessment of the] cranial nerves, coordination, balance, mental status, and reflexes. I always include an optic funduscopic exam for papilledema,” says Kathryn A. Boling, MD, a primary care physician at Mercy Medical Center in Baltimore, Maryland.

“The neurological exam should not take more than 5 to 7 minutes. Checking for papilledema is the most important part. A primary headache should have no neurological findings,” says Dr Newman.

The Agency for Healthcare Research and Quality (AHRQ) recommends the following guidelines to diagnose a headache. 1

  • Headache history should include onset, location, associated symptoms, precipitating factors, severity, coexisting conditions, and response to medications.
  • Physical examination should include neurologic screening, neck examination, blood pressure measurement, and evaluation of the temporomandibular joints.
  • Screening neurologic examination should include assessment of mental status and cranial nerves, funduscopy, pupil reaction to light and movement, visual fields, 4-limb testing for weakness, and evaluation of reflexes, coordination, and gait.
  • AHRQ does not recommend routine imaging or electroencephalography.

First and Worst: Looking for the Red Flags

“First and worst” is a common phrase used to describe red flag headaches. 1,2 “A first headache [occurring] after age 50 is most likely to be a secondary headache that requires treatment in an emergency department (ED). These include headaches caused by stroke, bleeds, and tumors,” says Dr Newman.

The following red flags prompt immediate presentation to an ED.

  • Thunderclap headache is a severe headache that reaches peak intensity within 1 minute.1 “An explosive headache that gets worse on exertion is [considered] hemorrhage until proven otherwise,” says Dr Newman.
  • Headache with fever and stiff neck suggests bacterial meningitis.1 “Any headache associated with fever and meningismus is an emergency headache,” says Dr Boling.
  • Headache with papilledema and altered consciousness or focal neurologic signs may indicate a space-occupying lesion and risk for transtentorial herniation.1
  • Headache with red eye, nonreactive and dilated pupil, or other visual disturbance with nausea and vomiting should be immediately evaluated for acute angle-closure glaucoma. 1