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Secondary headache — red flags
Most headaches are primary, but the aim in every question is to spot the red flag that demands urgent work-up: sudden onset, fever, a neurological deficit, age over 50, a change in pattern, or a link to posture and exertion.
Why it matters in the exam
Questions present a headache with one "small" detail — jaw pain on chewing in an older woman, pain worse lying down and on coughing, pain that eases lying down after a lumbar puncture, several household members with headache in winter, or daily analgesic use. The right answer depends on naming the secondary cause: giant cell arteritis, a tumour, intracranial hypotension, carbon monoxide poisoning or medication-overuse headache. A classic distractor is waiting for a biopsy before giving steroids in giant cell arteritis.
Key points
- Red flags: sudden onset, fever, neurological deficit, age over 50, pattern change, link to posture and exertion.
- A sudden headache needs immediate CT, then lumbar puncture or vessel imaging.
- In suspected giant cell arteritis give prednisone 40 to 60 mg at once and do not wait for the biopsy.
- Pain on standing that eases lying down suggests intracranial hypotension.
- Analgesics 15 days or more a month or triptans 10 days or more define overuse.
Summary table
| Red flag | Suspect | Next step |
|---|---|---|
| Sudden onset peaking within a minute | Subarachnoid haemorrhage, dissection, reversible cerebral vasoconstriction syndrome (RCVS), pituitary apoplexy | Immediate CT, then lumbar puncture or vessel imaging |
| Fever, neck stiffness, immunosuppression | Meningitis or encephalitis, abscess | Blood cultures, empirical treatment, lumbar puncture according to imaging |
| Age over 50 with new headache, jaw claudication, temporal artery tenderness | Giant cell arteritis (GCA) | ESR and CRP, prednisone 40 to 60 mg daily at once, biopsy or ultrasound without delaying treatment |
| Worse lying down, on coughing or exertion; papilloedema | Tumour or raised intracranial pressure | MRI with contrast |
| Pain on standing that eases lying down | Intracranial hypotension (CSF leak) | MRI with meningeal enhancement; epidural blood patch |
| Simple analgesics 15 days or more a month, or triptans and opioids 10 days or more, for over 3 months | Medication-overuse headache | Stop the overused drug and start prevention |
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Sources
- International Classification of Headache Disorders, 3rd edition (ICHD-3), 2018 — Secondary headaches and medication-overuse headache
- SNNOOP10 list (Do et al., Neurology), 2019 — Red and orange flags for secondary headache
- EULAR Recommendations for the Management of Large Vessel Vasculitis, 2018 — Giant cell arteritis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.