American Board of Internal Medicine (ABIM) Certification Practice Exam

Which of the following is a clinical red flag for secondary headaches?

1. Progression or fundamental change in headache pattern

2. Headaches that improve with rest

3. Headaches occurring only during sleep

4. Headaches exclusively on one side

The correct answer is: Progression or fundamental change in headache pattern

A progression or fundamental change in headache pattern is a significant clinical red flag for secondary headaches. This type of change can indicate an underlying medical condition that may require further investigation. For example, if a patient who previously had episodic tension-type or migraine headaches experiences a marked increase in frequency, severity, or a transformation to a chronic headache pattern, it could be a sign of a more serious issue such as a mass lesion, hemorrhage, or other structural abnormalities in the brain. Other manifestations and characteristics of headaches can provide important context but do not carry the same level of concern as a change in pattern. For instance, headaches that improve with rest are often associated with primary headache disorders like tension-type headaches or migraines. Headaches occurring only during sleep may indicate benign night-time headaches, rather than a serious underlying condition. Similarly, headaches that are exclusively unilateral (one-sided) can be characteristic of migraine or cluster headaches but do not inherently suggest a secondary cause unless accompanied by other concerning symptoms. In summary, a fundamental change in headache pattern is particularly alarming for clinicians as it can point to potentially serious underlying conditions that may require immediate evaluation and intervention.