Today, I review, link to, and excerpt from Emergency Medicine Cases‘ Ep 161 Red Flag Headaches: General Approach and Cervical Artery Dissections.*
*Helman, A. Shah, A. Baskind, B. Episode 161 Red Flag Headaches: General Approach and Cervical Artery Dissections. Emergency Medicine Cases. November, 2021. https://emergencymedicinecases.com/red-flag-headaches-cervical-artery-dissections. Accessed 9-22-2025.
All that follows is from the above resource.
In this Part 1 or our two part podcast series on Red Flag Headaches we discuss a general approach, tips and tricks to assessing patients who present with headache followed by a deep dive into cervical artery dissections. With the help of Dr. Roy Baskindand Dr. Amit Shah we answers questions such as: what are the big 4 headache diagnoses that are not routinely picked up on plain CT or LP? Why are the symptoms of cervical artery dissection often fluctuating? Why do the symptoms of cervical artery dissection sometimes seem to not fit an anatomical distribution? What are the key clinical features that would trigger you to suspect cervical artery dissection? How do you decide which patients require a CT angiogram? What is the evidence for a causal relationship between chiropractic manipulation and cervical artery dissections? What is evidence for antiplatelet agents, anticoagulants and thrombolysis in the management of cervical artery dissection? Which patients with cervical artery dissection can be safely discharged from the ED and many more…
Podcast: Play in new window
Go to part 2 of this 2-part podcast on red flag headaches
The big 4 causes of emergency headaches that are not routinely identified on plain CT
Headaches are one the most common ED presentations. About 98% of these patients have a benign cause of their headache. Of the remaining 2%, 1% can be diagnosed with a CT head or LP, such as a subarachnoid hemorrhage or meningitis, however the final 1% causes of headaches cannot be ruled out on plain CT/LP alone. The big four commonly missed emergency causes of headaches that cannot routinely be ruled out on plain CT:
- Cervical artery dissection (carotid and vertebral)
- Cerebral venous thrombosis (CVT)
- CO poisoning
- Giant cell arteritis
In this part 1 of our 2-part podcast on red flag headaches we focus on a general approach to headaches in the ED and cervical artery dissection – one of the big five causes of emergency headaches that does not show up routinely on plain CT, requiring a CT angiogram of the head and neck to confirm the diagnosis.
Some clinical pearls for headache assessment
- Headaches can arise from referred pain from the neck and neck pain can arise from referred pain from the head; include neck pathology in patients who present with headache and vice versa
- Clinical features that should trigger the consideration for a serious cause of headache include rapid onset of pain within minutes, repeat visits to ED for the same headache, exertional headache, different to previous headaches, focal neurologic findings, papilledema, immunocompromised state, loss of vision and abnormal vital signs
Dr. Baskind’s general approach to headache differential diagnosis: MY BRAIN HURTS
R: Posterior Reversible Encephalopathy Syndrome (PRES) from StatPearls. Last Update: June 14, 2024.
Update 2021: Tertiary pediatric center study of using rapid sequence brain magnetic resonance imaging (RS-MRI) as a feasible screening tool in 105 children (<12 years old) with persistent/recurrent headaches. 77% out of 105 cases were normal, 23% were abnormal; notably, 75% diagnosed with sinusitis, and 1 case with an abnormal brain mass. Abstract
Dr. Baskind’s physical examination tips suggesting specific diagnoses for patients presenting with headache
