History and Examination

Consider the use of headache diaries and appropriate assessment questionnaires to support the diagnosis and management of headache.

Ask about the following aspects of headache:

• Chronology:
  • why presenting now?
  • how recent in onset?
  • frequency pattern - episodic, or daily and/or unremitting
  • length of time of episode
• Character:
  • intensity of pain
  • nature and quality of pain
  • site and spread of pain
  • associated symptoms
• Exacerbating/alleviating factors:
  • predisposing and/or trigger factors
  • aggravating and/or relieving factors
  • what medication has been and is used, in what manner and with what effect?
• How much is activity (function) limited or prevented?
• State of health between attacks:
  • completely well, or residual or persisting symptoms
  • concerns, anxieties, fears about recurrent attacks and/or their cause
  • family history of similar headaches
• Focused physical examination:
  • Vital signs
  • Examination of extracranial structure, such as:
    • carotid arteries - with particular reference to dissection or aneurysm/murmur
    • sinuses
    • scalp arteries in the over 50's
    • cervical paraspinal muscles for abnormalities
  • Examination of the neck flexion

Neurological examination including

• BP and Fundoscopy

Follow up more detailed exam could include :

• Assessment of patient's awareness and consciousness, presence of confusion, and memory impairment
• Ophthalmological examination
• Cranial nerve examination
• Symmetry of muscle tone
• Sensation
• Plantar response(s)
• Gait, arm and leg coordination

Transfer immediately to secondary care

Refer patient immediately (within a day) to hospital for specialist assessment if patient presents with a:

Thunderclap headache

• severe headache rising to maximum crescendo within a minute
• worst ever headache

Orgasmic headache

• if history very recent

NB if over one week since last event - avoid sex and refer for urgent outpatient appointment

Suspected meningitis/encephalitis (A combination of all or some of the following):

• fever
• neck stiffness
• focal signs
• features suggestive of a central nervous system (CNS) infection

Temporal arteritis

• check inflammatory markers (normal in 5% of cases)
• always consider in patients over 50 years
• If diagnostic uncertainty contact Rheumatology consultant mobile phone 07920 781631 answered between 12.45-1.45; or Rheumatology SpR via switchboard

Acute glaucoma

• headache associated with red eye, halos or unilateral visual symptoms − consider angle closure glaucoma

Carbon monoxide poisoning

• non-specific headache
• enquire re heating devices and whether other household members have similar symptoms

Exercise headache

• 10% will have a secondary cause
• Need image/scan

NB Pre-orgasmic headache alone probably doesn't warrant an urgent referral but obviously can be associated with exercise! (see above)

NB Exercise headache should not include exercise induced migraine that occurs in a patient that has a migraine at other times.

Non-vascular intracranial disorders
(such as intracranial neoplasm)

• Red flags (risk more than 1%)
• Image/scan or refer 2ww neurology
• Associated relevant neurological signs
• Associated with new onset seizure
• NB Brain tumours rarely present with headache alone
• Headache associated with brain tumour is often mild and can occur anytime
• When an adult under 50 presents to their GP the risk of tumour is 0.09% and adults over 50 is 0.2%

2ww/Urgent referral

• Refer patient urgently with symptoms related to the CNS, including:
  • progressive neurological deficit
  • new-onset seizures
  • headaches
  • mental changes
  • cranial nerve palsy
  • unilateral sensor neural deafness in whom a brain tumour is suspected
  • headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
    • vomiting
    • drowsiness
    • posture-related headache
    • pulse-synchronous tinnitus or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory #
    • a new, qualitatively different, unexplained headache that becomes progressively severe
    • suspected recent-onset seizures (refer to neurologist)

• Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
  • sub-acute focal neurological deficit
  • unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
  • personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour.

• Refer urgently patients previously diagnosed with any cancer who develop any of the following symptoms:
  • recent-onset seizure
  • progressive neurological deficit
  • persistent headaches
  • new mental or cognitive changes
  • new neurological signs

Orange Flags (risk more than 0.1-1%)

Need careful monitoring and should carry a low threshold for image/scan or referral to GPwSI or neurologist:

• Significant unexplained change in headache character
• Headache precipitated by Valsalva manoeuvre
• New headache in a patient older than 50 years
• Headache that wakes from sleep (not migraine or cluster)
• Headache where diagnosis can't be made 8 weeks from presentation
• Primary cancer elsewhere
• Immunosuppressed or HIV

Most headaches can be managed in primary care but sometimes there is diagnostic uncertainty. Resistance to treatment can also be a problem (See referral criteria).

Headaches to consider managing in primary care

Primary headaches:

• Migraine – refer to GPwSI if difficult to manage, chronic migraine, uncertain diagnosis
• Tension - type headache – refer to GPwSI if difficult to manage, uncertain diagnosis
• Trigeminal neuralgia
• Medication overuse headache – refer to GPwSI if treatment resistant

Secondary headaches:

• Referred pain from nerve entrapment (whiplash)
• Substance withdrawal:
  • nitrates
  • calcium channel blockers
  • analgesics inc. triptans
  • medication overuse
  • CO poisoning
  • Caffeine withdrawal, in patients consuming frequent caffeinated drinks such as tea, coffee, or colas
• Disorders of homeostasis
  • sleep apnoea
  • fasting
  • dehydration
• Psychiatric disorders
  • somatization disorder
• Sinusitis

Referral Criteria

Headaches to consider referring to GPwSI

The following headaches could be referred to a GPwSI:

• Medication overuse headache
• Migraine
• Tension headache
• Change in nature of headache in any patient age 50 years and older
• Cluster headache - All new cases will need MRI

Exclusions

• One of the St Thomas headache clinic exclusion criteria is headaches where a serious secondary pathology is likely. Headaches to refer to secondary care (see red flag section)
• The secondary headache disorders, in which the headache can be attributed to another condition e.g. sleep apnoea. Referrals should be made to the appropriate specialty.

Referral Instructions

Headaches to consider referring to GPwSI – St Thomas Headache Clinic (see link in supporting information)

St Thomas Headache Clinic has a contract to take referrals from practices within the NHS Devon area. This should be done through the Devon Referral Support Services (e-Referral Service).

Any referrals outside this area are extra contractual referrals and must be accompanied by a letter of funding agreement from the relevant ICB.

Can also accept self-funded referrals by arrangement but this must be done through a GP referral.

e-Referral Service

• Specialty: Neurology
• Clinic Type: Headache
• Service: DRSS-E-Neurology (not for patient attendance)-Devon ICB-15N

St Thomas Headache Clinic can also accept self-funded referrals by arrangement but this must be done through a GP referral.

St Thomas are happy to see adults over 18 years as long as:

• the headache is not of short duration where a serious underlying pathology is suspected
• If in doubt please contact to discuss by either
  • E mail - sam.hotton@nhs.net or
  • Tel 01392 676679

Referral to secondary care

• e-Referral Service
  • Specialty: Neurology
  • Clinic Type: Headache
  • Service: DRSS-E-Neurology (not for patient attendance)-Devon ICB-15N

Referral Form

DRSS Referral Form

Patient Information

Exeter Headache Clinic

British Association for the study of Headache

Migraine Action

Migraine Trust

The Organisation for the understanding of Cluster Headache

Evidence

NICE – Headaches: Diagnosis and management

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: March 2015

Updated: May 2021