Clinical reference · Card 04 of 11 · Red flags
Red flags — SNNOOP10 and secondary cluster headache
Fifteen features that raise the probability of a secondary headache. Screen every new headache patient.
SSystemic symptoms, including fever
NNeoplasm history
NNeurologic deficit, incl. decreased consciousness
OOnset sudden or abrupt
OOlder age — onset after 65 years
PPattern change or recent onset of new headache
1Positional headache
2Precipitated by sneezing, coughing or exercise
3Papilloedema
4Progressive headache and atypical presentations
5Pregnancy or puerperium
6Painful eye with autonomic features — the cluster phenotype itself
7Post-traumatic onset of headache
8Pathology of the immune system, e.g. HIV
9Painkiller overuse or new drug at onset
CLUSTER-SPECIFIC CAVEATS• Item 6 — painful eye with autonomic features — is the cluster phenotype. It flags the need to exclude secondary causes, not to abandon the diagnosis.• Secondary cluster headache can be clinically indistinguishable from primary. Older onset, atypical duration or frequency, absent or bilateral autonomic features, and poor treatment response should prompt imaging.• Response to oxygen or sumatriptan does NOT exclude a secondary cause.• Dedicated pituitary MRI is not routinely indicated: adenoma prevalence in cluster headache (4.5%, 17/376) matches the general population.
SOURCES Do TP, Remmers A, Schytz HW, et al. Neurology 2019;92(3):134–144. PMID 30587518. Secondary CH: EAN guideline 2023. Pituitary: Grangeon L et al. Cephalalgia 2021;41(6):666–676.
Cluster headache tracking and analysis for patientsmyclusters.nlGet the printed setAll 11 cards, A6, printed back to back. The print-ready PDF unlocks when you request.