Many must-not-miss diagnoses manifest as a secondary headache. Though the DDx list is quite large, the pertinent questions that must be asked on history can be remembered using the mnemonic “SNOOP MEETS Pregnancy”1,2 Below you’ll find the cues associated with each letter, the symptoms they are associated with, and the differential diagnosis for some of those symptoms.
Systemic symptoms = fever, night sweats, weight loss, loss of appetite, protracted vomiting
- DDx: Meningitis, Encephalitis, Systemic infection, Lyme disease, Collagen vascular disease
Neurologic symptoms = focal neurologic signs (classically CN6), confusion, impaired alertness or consciousness, seizures
- DDx: Mass lesion, Stroke, Vascular malformation, Collagen vascular disease, Carotid or vertebral artery dissection, Acute angle closure glaucoma, Venous sinus thrombosis
Onset sudden or abrupt
- DDx: SAH, Pituitary bleed, Hemorrhage into mass, CNS infection, Acute angle closure glaucoma, Hypertensive emergency
Older >50 years
- DDx: Mass lesion, Temporal arteritis
Progression or pattern change = change in attack frequency, severity, or clinical features
- DDx: Mass lesion, Subdural hematoma, Medication overuse
Morning worse = headache awakes the patient
- DDx: Mass lesion
Exertion / posture / sexual activity worsens headache
- DDx: Idiopathic intracranial hypertension, Carotid or vertebral artery dissection, SAH
Exposure Hx
- DDx: Illicit drug use, Toxins, CO poisoning
Trauma Hx
- DDx: Trauma
Secondary risk factors = HIV, cancer
- DDx: Meningitis, Brain abscess, Metastases
Pregnancy
- DDx: Pre-eclampsia, Venous sinus thrombosis, Pituitary apoplexy, Carotid dissection
This post was copyedited by Sean McIntosh.
References
Reviewing with the Staff
The above mnemonic provides a reasonable approach to ensuring to the headache history for the junior learner. While advanced learners should have an appropriate headache history and physical exam that is driven by a differential, junior learners would do well to ensure that each of these items is reviewed to provide a complete history. Each of the findings must be reviewed in context as, alone, none of them are sensitive or specific enough to determine an investigation or treatment plan.
Sean Patrick
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