▪️ Danger signs (mnemonic SNNOOP10)
• Systemic symptoms including fever
• Neoplasm history
• Neurologic deficit (including decreased consciousness)
• Onset is sudden or abrupt
• Older age (onset after age 50 years)
• Pattern change or recent onset of new headache
• Positional headache
• Precipitated by sneezing, coughing, or exercise
• Papilledema
• Progressive headache and atypical presentations
• Pregnancy or puerperium
• Painful eye with autonomic features
• Post-traumatic onset of headache
• Pathology of the immune system or immunosuppressive therapy
• Painkiller overuse (includes analgesics, ergot, triptans)

▪️Medications
• anticoagulants, glucocorticoids, oral contraceptives,
• Analgesics can mask severe symptoms or sometimes exacerbate migraine
headache through a rebound effect (medication overuse headache).
• NSAIDs (including aspirin) and Sympathomimetics are also associated with intracranial bleeding.

‼️All anticoagulated patients with head trauma, even minor trauma, should undergo computed
tomography (CT).
☝🏻Many patients with a new nontraumatic headache will fall into the older age
group for whom imaging is already recommended.

✌🏻Apart from age and trauma, there are no high-quality data to help
determine whether to perform a routine cranial CT on anticoagulated patients.

• Patients with danger signs or other features suggesting a secondary headache source will require imaging.

▪️Emergency settings:
• CT is preferred.
☝🏻MRI as an initial examination is usually reserved for new headaches with optic disc edema or trigeminal pain, chronic headaches with new features, or headaches in the context of red flags (eg, known or suspected cancer, subacute head trauma, neurologic deficit, immunosuppressed state, pregnancy), keeping in mind that CT remains an alternative when MRI is unavailable.

▪️Nonemergency settings:
• Given that most headaches are benign, an MRI is usually preferred.

• Clinical suspicion of SAH in the setting of a negative or normal head CT.
• Clinical suspicion of an infectious, inflammatory, or neoplastic etiology of headache
• In cases of suspected idiopathic intracranial hypertension (pseudotumor cerebri)

‼️Vomiting in a migraineur who has never vomited with prior headaches raises concern for a secondary cause of the new headache.

‼️focal neurologic deficit should not be assumed to be related
to migraine unless similar deficits have occurred with prior migraines.

‼️Of note, patient response to analgesics should not be used as a diagnostic tool and should not dissuade performance of LP when indicated by history or examination

🔎hypnic headache: also known as "alarm clock headache," occurs almost exclusively after the age of 50 years and is episodes of dull head pain, often bilateral, that awaken the sufferer from sleep and resolve within four hours.(MRI without and with contrast)

💡The large majority of these patients will ultimately be diagnosed with either a migraine or
cluster headache.
▫️If acetaminophen has not already been taken by the patient, give a full dose.

▫️ketorolac 15 to 30 mg intravenously (IV) and prochlorperazine 10 mg.
• Haloperidol 2.5 to 5 mg IV or chlorpromazine 0.1 mg/kg IV might be used in place of prochlorperazine.
☝🏻Pretreatment with 12.5 mg of diphenhydramine or 1 mg of benztropine to avoid akathisia or other extrapyramidal symptoms.

‼️NSAIDs should be withheld in patients for whom there remains concern for a hemorrhagic
cause of headache or who may require a lumbar puncture (LP).

• Treating nausea and vomiting

• Other medications include sumatriptan, olanzapine, metoclopramide, and droperidol.

‼️The use of injectable opioids is strongly discouraged, but they may be necessary for patients with
contraindications to NSAIDs or medications with vasoconstrictive effects (eg, dihydroergotamine), or for
patients in whom prochlorperazine and diphenhydramine have not been effective.