Referral Pathways for Headache in Adults



Referral Pathways for Headache in Adults (June 2011)

Produced with the British Association for the Study of Headache

This pathway is not inclusive of all headache types. (See below for information on headache classification).

Referral patterns will depend on GP access to MRI/CAT and local availability of primary/secondary specialist headache services. This pathway should be adapted to reflect local circumstances.

Management guidelines and further resources are given below.

|IMMEDIATE assessment required: | |

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|Ref Hospital | |

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|Thunder clap headache | |

|Exclude subarachnoid haemorrhage | |

| |Severe headache rising to maximum crescendo within a minute |

| |Worst ever headache |

|Headache associated with possible | |

|Meningo/encephalitis | |

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|Malignant hypertension | |

| |Retinal changes |

| |BP > 200 systolic, 120 diastolic |

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|Headache following significant head injury | |

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|URGENT assessment required | |

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|Temporal arteritis |Always consider in patients over 50 years |

| |Inflammatory markers are normal in 5% of cases |

|Check inflammatory markers |Ideally urgent biopsy to confirm or commence steroid with |

| |clinical suspicion and arrange biopsy within 48 hours. |

| | |

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|Exercise headache |10% will have a secondary cause |

| |Those with recent onset need attention – longstanding ones are |

|Image/scan |likely exertional migraine and referred routinely |

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|Carbon monoxide poisoning |Non-specific headache |

| |Enquire re heating devices |

|Measure CO-haemoglobin | |

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|Venous sinus thrombosis |Non-specific progressive headache often frontal |

|Image/scan |Most common in pregnancy and thrombotic states |

| |Often associated with dehydration and patients may have |

| |papilloedema and present with seizures |

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| | |

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|Space occupying lesion | |

|Red flags (risk >1%) | |

|Image/scan |Associated relevant neurological signs |

| |Associated with new onset seizure |

|Orange flags (risk >0.1%-1%) |Significant unexplained change in headache character |

|Need careful monitoring and low threshold for Image/scan or |Migraine aura >1 hour |

|referral to GPwSI or neurologist |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 not be made 8 weeks from |

| |presentation |

| |Primary cancer elsewhere |

| |Immunosuppressed or HIV |

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|Diagnose Primary Headache | |

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|Exclude medication overuse headache |Any analgesia including Triptans taken on more than 3 days of |

|If treatment resistant refer to GPwSI or neurologist with an |the week on a regular basis |

|interest. |Non specific headache with a history of a prior primary |

|Difficult to manage and high relapse |headache |

| |Can obscure diagnosis of primary headache |

| |(See below for more information) |

| | |

|Cluster | |

|Refer to GPwSI or neurologist with an interest. All new cases |Excruciating unilateral peri-orbital pain lasting up to 3 hours|

|will need MRI. (Can be relaxed if stable cluster present for |– the cluster attack |

|some time) |Unilateral autonomic features |

| |Number of cluster attacks in a cluster period – classically 6-8|

| |weeks |

| |10% are chronic |

| |(See below for more information) |

| | |

|Migraine | |

|Refer to GPwSI or neurologist with an interest if: | |

|Difficult to manage |Recurrent severe, unilateral or bilateral (30%) pain with or |

|Chronic migraine |without aura lasting 4-72 hours (can be longer). |

|Uncertain diagnosis |May be associated with nausea |

| |May be associated with phonophobia, photophobia or movement |

| |sensitivity |

| |Two out of three of following positive has high sensitivity: |

| |three months recurrent headache; associated with nausea; light |

| |sensitivity more pronounced with headache. |

| |(See below for more information) |

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|Tension type headache |Dull, featureless, bilateral pain |

|Refer to GPwSI or neurologist with an interest: |Cause unknown but often associated with anxiety/depression |

|Difficult to manage |Reassurance and amitriptyline |

|Uncertain diagnosis |(See below for more information) |

APPENDIX

Classification of Headache

Headache was first formally classified in 1986 and revised 2004. The brain has no sensory fibres. Intracranial pain arises from invasion, stretching, pressure on or inflammation of meninges. The two main classifications of headache are primary and secondary.

Primary headache

No underlying cause demonstratable - 90% of GP presentations. Problem lies in underlying cellular defects.

Migraine 85% of GP presentations.

• Severe episodic pain with or without aura associated with nausea, photophobia and phonophobia.

• 5% chronic migraine, >15 days each month. Usually history of episodic migraine.

Tension type headache - 10% of GP presentations but high population prevalence. Poorly understood. If occurs in migraine sufferer probably part of migraine spectrum.

• Dull, pressing pain usually bilateral with no nausea, photophobia or phonophobia.

• Episodic or chronic. Reassurance and amitriptyline first line approaches.

Cluster headache and other autonomic cephalalgias ................
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