Transcript: Diagnosing Headache In Primary Care Red Flags

Liz Rohr:
Well, hey, there, it's Liz Roar from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Liz Rohr:
Hello. We are going to talk today about red flags of headaches. Headaches are a doozy of a chief complaint because they're such a broad differential. Like so many of the topics I've talked about in episodes so far, headaches are really a tricky one. So the reason I want to focus on red flags in this episode, is because the way that we get to that confident place of like, "You know what, this is what I think this headache is from. Here are the differentials. I'm pretty confident going forward." The way that we get there, it's just a gradual process. Like most of the really tricky chief complaints, we have to start with the kind of basics, the old card onset, location, duration, all of those history questions. And then understanding the red flags of headaches keeps us safe. And then as we build out our knowledge, we can be like, "Oh, okay."

Liz Rohr:
So spontaneous intracranial hypotension, I know all about that. Right? Come on. No, we're going to learn about that as we go. And so the red flags are those kind of anchoring pieces of like, "Okay, maybe, I don't know all the things about spontaneous intracranial hypotension." Right. But, you know what, we're just going to watch out for it. Right. So anyway, and then I want to talk about some red flags. Specifically what I want to focus on is an acronym, which you may or may not be familiar with. It's had a lot of names, but it's the SNOOP acronym. SNOOP 10, I think is the most updated one. And I want to walk through that and kind of give some examples of context.

Liz Rohr:
SNOOP, right. S is the first one. The first thing you want to watch out for when it comes to a headache is do they have any systemic symptoms? Do they have other things going on in their body? Even if you aren't from... You know what, you're not listing off all of those differentials, is there anything systemic going on? Do they have a fever or chills, most specifically, right. Do they have a rash? Do they have other things going on? And that can be tied into things like meningitis, for example. So, first things first. Start with the S. I got my little notes over here.

Liz Rohr:
There's two Ns. The first, most important N. These are some hopefully helpful hack pathways that you can be like, "At least, even if I don't know all of the differentials, I know these red flags." The next one is neurologic symptoms, neurologic deficits. So, I was a new grad, and even to this day, when I have a patient with a headache, and I'm not quite sure what to do with them, the first question is how is their neuro exam? If I didn't present that information to the person already. So neurologic exam is going to be so, so important. Anybody with a headache, we really want to be mindful of their neurologic status. Do they have any "focal deficits," quote, unquote?

Liz Rohr:
The next one is a history of neoplasm. So, we want to be mindful of, do they have a history of cancer? Could this be a brain tumor? And I want to pause there and say that pretty much every patient that comes in is worried about something that severe. It's our job to be worried about it. It is not a common reason, but it is an important history question to ask in the context of a person with a headache.

Liz Rohr:
With Os, there's two Os. SNOOP, two NS, two Os. So one of them is older age, which older, subjective, right? But basically it's referring to any patient over the age of 50. And a new onset of a headache over the age of 50, just has another level, another layer of differentials that could be more severe. And so, it's just one piece to keep in mind with a red flag. Somebody who is the age of 50 or older with a headache, does not necessarily mean that this is a red flag. They need urgent imaging, you have to send them to the ED. It's just one piece of information to keep in mind.

Liz Rohr:
O, the other O is really important. Well, these are all important obviously, but maybe I'll keep saying they're all important. I don't know. This second O, though, has to do with onset. Abrupt onset is very concerning with a headache. That's what you've probably learned about, or maybe even seen in real life, so far, of a thunder clap headache. So something that happened immediately quick onset. Especially in the context of somebody who was exercising or doing some sort of exertion and then had this sudden severe onset of a headache. That could be some sort of vascular condition. So, it's really important to be mindful of the abrupt onset patients.

Liz Rohr:
Okay. So the rest of them are Ps. There're a 10 Ps. There used to be a couple of Ps, and it feels like they just keep adding them. But it's nice, at least, that they're the same letter, right? So pattern change or a recent new onset. Again, this in and of itself is not necessarily an emergency. It's just a helpful context of, when you're talking to somebody who has a headache, is this a headache that you had before? Do you have headaches like this? Or is this drastically different than what you've had before? Because when there is a changing pattern, especially if it's progressive, that is more concerning for something more organically dangerous.

Liz Rohr:
Positional headache. So this one, I feel like... I would get this when I was a new grad. I would present my case, and then my colleague would be like, "Well, was it positional?" I'd be like, "What are you talking about?" So this one is referring to somebody who's laying flat or standing up. It's worse when they stand up, and then better when they're laying flat. Is typically the scenario that we're talking about. And this has to do with the zebra that I mentioned of spontaneous intracranial hypotension, or CSF leak, or some sort of more concerning acute process. So, even if you're not comfortable with all the differentials of what positional could mean, just keeping that in mind, as part of your history taking.

Liz Rohr:
The other context, I want to set around that, and I'm going to be making another video about migraines specifically, it's not necessarily that the movement around is troublesome. Because there are patients who have migraines for example, and exertion makes it worse because it's just a throbbing headache that if they're going for a walk, it's going to make it worse. So, that's not necessarily what I mean by positional or what's meant by positional. It has to do with position changes. There's a distinct difference between the position change that causes some sort of difference in their symptoms.

Liz Rohr:
Let's go for another P. This is precipitated by sneezing, coughing or exercise. I've already kind of mentioned this already. But when you have somebody who has a very sudden onset, especially in the context of that sort of exertional episode, that could be a vascular cause. Another P, Papilledema. This is a very challenging one where pretty much anybody who has a headache, you're going to do a focal neuro exam, full head to toe, probably in terms of your neurologic exam that you're going to be focused on. Papilledema is important to take a look at the intracranial pressure and all that. It is a very challenging exam to master. So, just do your very best to keep on practicing and always ask for help if you need it.

Liz Rohr:
Another P, progressive history or atypical presentations. It's sort of similar to what I've already said, but the context of people is that they... Most of the time patients who have headaches can tell you what their history is versus if this is a brand new, they've never had this type of headache before, definitely tread cautiously.

Liz Rohr:
Pregnancy, hundred percent. Anytime I have a patient who is pregnant with a headache, I am getting somebody else involved, because there are other things to be considered for a patient who is pregnant and it could be a lot more serious. Post-traumatic onset, another P. So if somebody has some sort of head injury or some sort of trauma, and then they get the severe headache, that is much more concerning. Painful eye. If somebody has a painful eye, it could be more associated with another sort of underlying condition. Two more Ps, pathology of the immune system. So if somebody has something like HIV or something underlying with their immune system going on and they have a severe headache, they just have a lot more medical complexity to keep in mind, and it really broadens the differential diagnosis. So again, it's not that the patient has, for example, HIV, it's just that it's introducing a broader differential that could be a higher risk.

Liz Rohr:
The last P is pain killer overuse. And I don't know, this is not necessarily a red flag, but I'm sure you are familiar with medication overuse headaches. So, it's just one extra thing to kind of keep in mind that we just want to be mindful of, but it's not necessarily, you need to send them to the ED right now. So, of those SNOOP 10s who needs urgent evaluation? Pretty much, we can kind of siphon it down a little bit more. So sudden thundercloud headaches, where it's like a rapid onset, I know it's a difficult decision to make, to send somebody to the ER, but most of the time, those patients need to go. The other one is a first or worst headache of their life.

Liz Rohr:
You really want to tread cautiously. I've been in that uncomfortable situation of, do I send them, do I not send them? That is one potential area to consider. The deciding factor in those types of situations is typically their neurologic exam. So, if you have any focal neuro deficits, those patients definitely need emergent care and imaging. The other context that you want to think about emergent care for patients are when they have things if you're worried about a meningitis or encephalitis, they have a neck pain, they have systemic symptoms, especially with focal, neurologic deficits. And if you also have any periorbital symptoms as well, we don't want to mess around in that area. And then the last thing is... This is a pretty rare one, but is there any possible carbon monoxide poisoning? Hopefully you've gotten that in your history in terms of the context of what's going on for their evaluation.

Liz Rohr:
But those are for the most part, the reasons that those patients would need emergency evaluation. So down below, I'm going to write a little list of all of the SNOOP acronyms. So you can just kind of copy and paste that, and you can put that into your HPI. And then hopefully that will kind of help you trigger those types of questions. And hopefully, in this video, I've kind of fleshed out that acronym a little bit more for context, so that you can apply it more comfortably.

Liz Rohr:
And again, you have to do your due diligence of assessing the underlying reason for the headaches. But if you can incorporate or start incorporating that acronym in terms of your red flags, you can at least comfortably say, "Hey, we can take a pause. We can evaluate further. We can try some medications. We can do more assessment. We don't have to do anything emergent in terms of imaging or referrals or anything like that." So, if you haven't grabbed the ultimate resource guide, head over to realworldnp.com/guide, you'll get these episodes sent straight to your inbox every week with notes from me, patient stories and bonuses I really just don't share anywhere else. Thank you so much for tuning in. We'll talk to you soon.