‘DO NOT MISS’: A mnemonic to detect red flags in headache and back pain syndromes

Sir,

Pain management is crucial for clinicians across all specialities of medicine and surgery. The first step in effectively managing pain is a thorough evaluation to rule out any ‘red flag’ features suggestive of a serious underlying disorder. In the case report on spinal mucormycosis, ¹ the patient experienced a persistent headache with visual blurring for three months – an obvious ‘red flag’ feature that was overlooked, leading to a delayed diagnosis of chronic meningitis and mucormycosis, which eventually disseminated, causing increased morbidity.

During my MD residency, I encountered a similar situation in the emergency department (ED). One of my seniors requested the admission of a middle-aged patient with a headache of mild to moderate intensity for a few weeks. While the headache was not associated with vomiting, visual disturbances, or fever, I questioned the necessity of ED hospitalisation, given the bed shortages in our large public hospital, where patients often stay in the ED for over 72 h before being transferred. ² The patient's general physical and neurological examinations were unremarkable. However, he had diabetes and mentioned elevated home glucose levels for the past few weeks. A fundoscopic exam revealed suspected papilloedema, later confirmed by an ophthalmologist. A computed tomography of the head was unremarkable, but a lumbar puncture showed cerebrospinal fluid pleocytosis, elevated protein, and low glucose. India ink staining revealed yeast and a positive cryptococcal antigen confirmed the diagnosis. HIV serology was negative. The patient was successfully treated with intravenous amphotericin and fluconazole.

Such cases underscore the importance of identifying ‘red flag’ features for pain syndromes, which can often be missed in a busy primary care or emergency setting. To aid in daily clinical practice, I propose the mnemonic ‘DO NOT MISS’, for common red flags associated with headache and back pain syndromes (Box 1).^3–5

Box 1.

‘Red flag’ features associated with a serious underlying disorder in patients with headache or back pain (acronym – “DO NOT MISS”).

Diurnal variation: Headache upon awakening or back pain worse at night/rest.

Onset in older age: >55 years for headache, >70 years for back pain.

Neurological deficits or abnormal neurological examination.

Other associated symptoms: Headache preceded by vomiting, back pain associated with urinary/faecal incontinence or abdominal/pelvic mass.

Tenderness: Headache with tenderness over the temporal artery or back pain with focal midline spinal tenderness.

Malignancy: Current or prior history.

Immunocompromised states: HIV, steroid use, uncontrolled diabetes.

Systemic features: Unexplained fever or weight loss, known systemic illness.

Severity: “Worst” headache ever or worsening pain intensity over days or weeks.