Headache “Red Flags”: When to See Your Doctor

By Todd J. Schwedt, MD, FAHS

Although painful and often disabling, the vast majority of headaches are not due to worrisome underlying problems. However, the presence of certain symptoms suggests the need to be evaluated by your doctor. These headache “red flags” include:

  1. Thunderclap Headache: very severe headache that reaches its maximum severity immediately (within a couple of minutes). Thunderclap headaches require emergent medical evaluation.
  2. Positional Headache: headache that substantially changes in intensity in association with changes in position – e.g. standing from lying or vice-versa.
  3. Headaches Initiated by Exertion: headache starting while coughing, sneezing, and/or straining.
  4. New Headaches: especially if older than 50 years of age, or if there are medical conditions that make worrisome headaches more likely (e.g. cancer, blood clotting disorder).
  5. Substantial Change in Headache Pattern: significant increase in headache frequency or significant change in headache characteristics
  6. Constant Headache Always in the Same Location of the Head
  7. Worrisome Neurologic Symptoms: about 1/3 of people with migraine have neurologic symptoms (“migraine aura”) that typically precede onset of a migraine headache. Commonly, aura symptoms consist of slowly spreading visual symptoms sometimes accompanied by tingling of the face and upper extremity. These symptoms resolve within 60 minutes. If these symptoms have immediate onset (as opposed to a slow progression of symptoms), last longer than 60 minutes, or do not completely resolve, medical attention is required. Medical attention is also required if other symptoms are present, such as weakness of one side of the body, change in level of consciousness, significant difficulty walking, or other symptoms that worry you.
  8. Headache that never goes away
  9. Systemic symptoms: including fever, chills, weight loss, night sweats

If any of these headache “red flags” are present, your doctor will want to evaluate you by asking questions about your headaches and general health, and by performing physical and neurologic examinations. Based upon these assessments, your doctor will be able to determine if further tests are needed.

Todd J. Schwedt, MD, FAHS, Professor of Neurology, Mayo Clinic, Phoenix, AZ.