Red Flags Symptoms In Patient Presenting With Headache

A 23-year-old presents for review. For the past 3 months or so he has been having problems with frequent headaches. These are now occurring on an almost daily basis and can be severe at times. Which one of the following features should prompt investigation for a secondary cause of headaches?

A. Photophobia during the headache
B. Feeling of nausea during the headache
C. Severe unilateral eye pain
D. Headache worsens on coughing
E. Numbness lasting 30 minutes before the headache

Answer:
D. Headache worsens on coughing

Discussion:
Headache: Red flags :
Headache is one of the most common presenting complaints seen in clinical practice. The vast majority of these will be caused by common, benign conditions. There are however certain features in a history which should prompt further action.
In the 2012 guidelines NICE suggest the following:
 compromised immunity, caused, for example, by HIV or immunosuppressive drugs
 age under 20 years and a history of malignancy
 a history of malignancy known to metastasis to the brain
 vomiting without other obvious cause
 worsening headache with fever
 sudden-onset headache reaching maximum intensity within 5 minutes
 new-onset neurological deficit
 new-onset cognitive dysfunction
 change in personality
 impaired level of consciousness
 recent (typically within the past 3 months) head trauma
 headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
 orthostatic headache (headache that changes with posture)
 symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
 a substantial change in the characteristics of their headache