Headache pathway

Referral criteria for headache referrals to secondary care

Key points When to refer to a Specialist
(Consider referring to ED depending on presentation and waiting OPD time)
• Migraine, TTH and MOH are most common headache disorders and in most cases
Diagnostic uncertainty, including unclassifiable, atypical headache
not difficult to manage → initial primary care management recommended
• Good management of most headache disorders requires monitoring over time Diagnosis of any of the following:
• History is all-important, there is no useful diagnostic test for primary headache • Chronic migraine (patients who have failed at least one preventative agent)
disorders and MOH • Cluster headache
• Headache diaries (over few weeks) are essential to clarify pattern and frequency of • SUNCT/SUNA>
headaches, associated symptoms, triggers, medication use/overuse
• Persistent idiopathic facial pain
• Special investigations, including neuroimaging, are not indicated unless the
history/ examination suggest secondary headache • Hemicrania continua/chronic paroxismal hemicranias
• Sinuses, refractive error, arterial hypertension and cervicogenic problems are not • Trigeminal neuralgia
usually causes of headaches Suspicion of a serious secondary headache (Red flags)
• Opioids (including codeine and dihydrocodeine) not to be prescribed in migraine • Progressive headache, worsening over weeks or longer
Assessment of patients with headache • Headache triggered by coughing, exercise or sexual activity
Full history, including: • Headache associated with any of the following:
- age of headache onset (if >50 years consider Temporal arteritis ) - postural change (indicative of high or low intracranial pressure)
- special attention to any new headache or significant change in existing headache - papilloedema
- duration of headache: - focal neurological deficit or seizures
Chronic migraine (longstanding and continuous; previously intermittent) vs - rapid progression of unexplained cognitive/personality/ behavioral change
New Daily Persistent Headache (usually recent and continuous) vs - unexplained fever
Trigeminal or occipital neuralgia (paroxysmal) - weight loss or poor general condition
- frequency (if very frequent must suspect medication overuse) New headache:
- any specific warning features (see “Red flags”) • Presenting as thunderclap (intense headache with “explosive”/abrupt onset)
- medications (if MOH suspected – stop analgesics and caffeine; COCP in migraine) • In a patient ≥ 50 years, check ESR/CRP and refer
Examination (mandatory if secondary headache suspected), including • New daily persistent headache (and no prior history of headache)
- Visual acuity; visual fields to confrontation and fundi • In a patient with risk factors for immunodeficiency or cancer
- Blood pressure • In a patient with family history of glaucoma
Patients with acute worst ever headache should be referred to ED Headache with atypical aura, especially
Abbreviations: TTH - tension-type headache
- prolonged (lasting> 1 hour) or including significant prolonged motor weakness
MOH - medication-overuse headache - new aura without headache in the absence of a prior history of migraine
TN – trigeminal neuralgia No Headache not responding satisfactory to management in primary care
SUNCT - severe unilateral neuralgiform headache with conjunctival injection + tears
SUNA - severe unilateral neuralgiform headache with autonomic features
Comorbid disorders requiring specialist management
NDPH - New daily persistent headache
Qol - Quality of life Initial primary care management
COCP – combined oral contraceptive pill
PIFP - Persistent idiopathic facial pain
 Migraine Migraine with aura Medication overuse TTH Cluster headache Other
Recurrent moderate/severe pain ≈ 1/3 of patients with • Daily or near-daily (≥15 Typically mild/moderate pain • Affects M:F (3:1 ratio) Should be recognised in
typically but not always: migraine d/month) without associated symptoms • Bouts last 6-12 weeks primary care, but may
• unilateral and/or pulsating Aura 5-60 minutes prior to • Aggravation of a prior Not worse with activity • Typically 1-2 x year require specialist
• lasting 4-72 hours untreated / with headache headache (usually Can occur in combination with • Rarely chronic management
• associated with Typical migraine or TTH) migraine throughout year
- nausea / vomiting • visual (>90% of auras): • Often worst early in the • Infrequent episodic TTH ≤ • Very severe pain, often Trigeminal neuralgia
- photo- ± phonophobia blurring is not morning once/month at night Triggered unilateral sudden
- aggravated by routine diagnostic; and/or • Great impact on QoL • Frequent episodic TTH • Strictly unilateral excruciating facial pain
physical activity, and disabling • unilateral sensory • Causally associated - attack-like episodes on 1–14 • Lasts 15–180 min Brief, often serial
• freedom from these symptoms Less common with regular use, over d/month, (commonly 30–60)
between attacks • brainstem (vertigo, >3 months, of: - lasting hours to few days; • Marked agitation Carbamazepine;
tinnitus, diplopia, - Opioids/ Triptans > 10 - usually generalised (bilateral) • Triggered by alcohol Oxcarbazepine; Lamotrigine;
Usually episodic ataxia); d/month - pressure or tightness, often • Accompanied by highly Gabapentin
Can be chronic (15% of cases): • speech and/or - Non-opioids > 15 spreading to the neck characteristic & strictly
• headache ≥15 d/month, of language d/month • Chronic TTH ipsilateral autonomic SUNCT / SUNA
which ≥8 d migrainous Rare - occurs on ≥15 days/month symptoms: Similar to TN (but frontal)
• often complicated by: • motor weakness • Usual acute migraine - may be daily and unremitting - red and watering eye; Autonomic ocular symptoms
- depression and/or anxiety therapy ineffective - may be associated with mild - rhinorrhea / blocked
- low back and/or neck pain Full recovery after attacks • Headache tends to nausea nostril Lamotrigine
- medication overuse worsen after analgesia +/- ptosis
withdraw, but in most Ice pick / stabbing
cases improves within 2 Sudden brief head pains
months Prompt referral at first Various locations
Acute attack (Restrict simple analgesia to max 6 d/month) and
presentation for specialist
review + MRI! Chr Paroxysmal Hemicrania
Prefer soluble analgesic, early in the attack, at an adequate dose Unilateral periorbital
• Simple analgesia (high dose aspirin, paracetamol, NSAID) ± Early intervention If infrequent, ≤2 days/week
Avoid oral triptans and Autonomic (red eye,
antiemetic, or if ineffective essential can be successfully treated
analgesics lacrimation, nasal
• Triptans (oral, nasal spray, sc injection) or Long-term prognosis with simple analgesia.
congestion, ptosis)
• Simple analgesia + triptan ± prokinetic antiemetic usually very good If frequency > 2 d/week –
Acutely 15-30 minutes; multiple/ day
increased risk for medication
• Avoid COCP if any aura / severe migraine • Nasal or sc triptan and
Withdrawal: use, consider prophylactic
• No triptan DURING aura • 100% Oxygen at ≥ Hemicrania continua
• Abruptly therapy:
12L/min until response, Unilateral “side-locked”
• Tapering over a period • 1st line:
or for ≥ 15 min constant headache >3 /12
of 2-4 weeks Amitriptyline 10-100 mg nocte
Specialist care +/- autonomic features
Prophylactic therapy (Restrict simple analgesia to max 6 d/month) • Replacing overused or
• Transition therapies Restlessness
drug(s) with Naproxen Nortriptyline (same dose)
- Prednisolone
Start any drug at a low dose and increase if no major SE; trial for ≥ 500 mg bd for max 3-4 less SE / less efficacy
- Occipital nerve block Indomethacin +PPI
8-12 weeks; tapered withdraw after ≥ 6 months of good control weeks • 2nd line:
• Maintenance
• Propranolol LA 80-160 mg od Mirtazepine 15-30 mg od
prophylaxis PIFP
• Amitriptyline 10-100 mg at night / Nortriptyline 10-100 mg Headache prophylaxis • 3rd line:
- Verapamil (ECG) Dull, daily persistent > 3/12
against antecedent Venlafaxine 75-150 mg od
• Topiramate 25mg od 2/52, titrate gradually to 50mg bd - Lithium carbonate Poorly localized facial and /
• Candesartan 8-16mg od headache may be (levels) or oral pain
• Sodium valproate 600-1500 mg/d (! not in women of child- introduced if intermittent - Topiramate (?efficacy) Often psychiatric
primary headache features comorbidity
bearing potential and pregnancy; Annual acknowledgment)
persist or emerge
• Flunarizine 5-10 mg od
Amitriptyline, Gabapentin,
Pregabalin