Dr McAllister is Medical Director at the New England Institute for Neurology and Headache and Chief Medical Officer for the New England Institute for Clinical Research and Ki Clinical Research, all in Stamford, Conn.
The great majority of headaches primary care providers will see in their office will be primary in nature – migraine, tension type, and cluster being the big 3. However, secondary headaches (in which the pain is generated by something ominous and potentially life-threatening) are lurking out there, and missing one could be disastrous. Consider the following case:
A 53-year-old man presents with a throbbing, occipital headache of 2 weeks’ duration, associated with light sensitivity and nausea. He has no prior headache history. The pain came on abruptly after intercourse, starting out as severe and currently of moderate severity. He also complains of fatigue and mental fogginess. Ibuprofen has not helped. A physician at a walk-in center suggested this was migraine, and prescribed sumatriptan 100mg, which has helped some. Exam is remarkable for elevated blood pressure (170/95 mmHg) and neck stiffness.
A. Concur that it is likely migraine and continue the sumatriptan
B. Refer to neurology (who are several months booked out)
C. Apply the SNOOP mnemonic and take appropriate action
If you chose C, congratulations, for SNOOP has proven itself very useful since the American Headache Society brought it out a dozen years ago. SNOOP is the most useful mnemonic in headache medicine, and one well worth committing to memory. SNOOP helps the busy clinician remember the hallmarks of secondary headaches – it facilitates medical decision making, and informs us of when to relax and when to sweat in the face of an unusual headache.