WATCH: Dr. Andy Lee on SNOOP-ing Around Before Diagnosing Migraine

Migraine is one of the most common neurological disorders worldwide, often presenting with a constellation of symptoms familiar to most clinicians: throbbing pain, nausea, vomiting, photophobia, phonophobia.

However, as Dr. Andy Lee, a neuro-ophthalmologist at Houston Methodist, emphasizes, not all that appears to be migraine is benign — or even migraine at all. In the whiteboard presentation above, Dr. Lee urges clinicians to check for signs of a more serious underlying pathology.

"What we'd like to do with patients who have migraine is not only make sure they meet the diagnostic criteria, but to snoop around," Dr. Lee explains. "And by snoop around, I mean look for these other features that would suggest this isn't migraine, and maybe it's something else causing a headache and looking like migraine."

Dr. Lee outlines a structured approach to identifying red flags that the issue isn't a migraine using the acronym SNOOP:

• Systemic symptoms: Check for irregularities with the heart, kidneys and lungs, as well as whether the patient is immunocompromised. "Systemic disorder patients sometimes get what seems like migraine, but it's not," explains Dr. Lee.
• Neurologic symptoms (other than headache): He says these include "ringing in the ears, focal deficits, weakness, numbness, tingling, double vision, which don't usually occur in migraine alone."
• Onset - age: "If it's a kid — less than 5 to 10 — or if they're older, that's a big red flag that you should be thinking of something other than migraine," Dr. Lee warns. "Most migraine patients present when they're young adults to middle-aged."
• Onset - speed of symptoms: The other way onset should be evaluated is in terms of how quickly the symptoms arose. If they're abrupt, acute, severe — being recounted as "the worst headache of my life" — that is a red flag to consider other causes.
• Precipitating event: Headaches triggered by laughing, coughing, sneezing, exercising or sexual intercourse may suggest increased intracranial pressure, and Dr. Lee recommends imaging the patient. "You're going to be making sure the patient isn't pregnant or postpartum. That is a big red flag that something related to the pregnancy or the delivery is causing the headache," adds Dr. Lee. Other precipitating events to consider are whether the pattern of symptoms is new for the patient, as well as whether papilledema is present at the back of the eye.

Ultimately, Dr. Lee's message is clear: while migraine is common, its presentation in neuro-ophthalmology warrants a vigilant and systematic evaluation. For ophthalmologists and other specialists encountering headache patients, Dr. Lee's insights offer a critical lesson: use SNOOP to evaluate common migraine symptoms to help identify a more serious underlying pathology.