SNOOPP: Recognizing red flags in your headache patients

Presented here are cues you can use to structure your thinking about ominous signs in the headache history which should lead you to be suspicious of a secondary headache disorder. A mnemonic, SNOOPP, can be used to review the signs and symptoms which constitute red flags.

S – Systemic signs and symptoms

N – Neurologic symptoms

O – Sudden onset

O – Older (patient or presentation)

P – Progressive

P – Positional change, Precipitators, Papilledema

These signs might include weight loss, fever, chills, myalgia, and anorexia.

Systemic signs may occur secondary to medical conditions such as human immunodeficiency virus (HIV), cancer, vasculitides, infections (for example septic or aseptic meningitis and early encephalitis), and cerebrovascular disorders which may present with a headache.

This might include focal changes such as reflex abnormalities, weakness, alterations of consciousness, confusion, or cranial nerve deficits.

We need to be alert for possible structural abnormalities such as stroke or tumor or disc derangement in the brain or upper spinal cord which could influence the exam and provoke headaches.

We should also consider bone tumors, metastatic cancer, and carcinomatosis.

Was the headache gradual or sudden in onset?

In the case of a sudden onset headache, we must watch out for the most serious cause: a hemorrhage. A thunderclap headache also presents with a sudden onset.

This refers not only to the patient’s age but also the headache circumstance.

First, is the patient over age 50 with a new headache? This might be giant cell arteritis or glaucoma.

Is this current headache a new presentation of headache (a change in their usual headache)? Or is it an old or typical headache circumstance for this person?

We compare this current patient presentation to previous headaches to determine if it is getting worse.

Does a positional change induce the headache? This is something we see with cerebrospinal fluid leak and resulting intracranial hypotension.

Precipitators such as a Valsalva maneuver or certain activities such as bending or jumping sometimes indicate increased intracranial pressure.

Papilledema is a significant finding in increased intracranial pressure.

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.