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 neurology:

• 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.

Headaches to consider managing in primary care

Primary headaches:

• Migraine 
• Tension 
• Trigeminal neuralgia
• Medication overuse headache 

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 to secondary care

• 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.

• 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

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: April 2025