Referral criteria from primary care - possible migraine headache
Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral (1):
- worsening headache with fever
- sudden-onset headache reaching maximum intensity within 5 minutes
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically within the past 3 months) head trauma
- headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
- headache triggered by exercise
- orthostatic headache (headache that changes with posture)
- symptoms suggestive of giant cell arteritis
- symptoms and signs of acute narrow angle glaucoma
- a substantial change in the characteristics of their headache
Consider further investigations and/or referral for people who present with new-onset headache and any of the following:
- compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- age under 20 years and a history of malignancy
- a history of malignancy known to metastasise to the brain
- vomiting without other obvious cause
Consider further investigations and/or referral for people who present with or without migraine headache and with any of the following atypical aura symptoms (1)
- motor weakness or
- double vision or
- visual symptoms affecting only one eye or
- poor balance or
- decreased level of consciousness
Consider specialist referral and/or inpatient withdrawal of overused medication for people who are using strong opioids, or have relevant comorbidities, or in whom previous repeated attempts at withdrawal of overused medication have been unsuccessful (1)
A review noted (2):
- referral from primary care is indicated if there are atypical symptoms leading to diagnostic uncertainty, a failure to respond to recommended migraine management strategies, or comorbidities that require a more complex treatment approach
Clinical features suggesting Secondary Causes of Headache and Reasons for Neurologic Referral
- systemic symptoms (including fever)
- history of neoplasm
- neurologic deficit or dysfunction (including decreased consciousness)
- abrupt onset of headache e.g. thunderclap headache [explosive onset of headache with rapid progression over seconds to minutes])
- onset of headache begins after age 50 y
- pattern change or recent onset of headache
- positional headache
- headache is precipitated by sneezing, coughing, or exercise
- presence of papilloedema
- progressive headache and atypical presentations
- pregnancy or puerperium
- painful eye with autonomic features
- posttraumatic onset of headache
- headache associated with pathology of the immune system, such as HIV
- history of painkiller overuse or new drug at onset of headache
With respect to NICE guidance with respect to suspected brain tumour (3,4):
The updated NICE urgent referral guidance for suspected brain tumour (3) is much less specific than the previous guidance (4).
The current guidance states (3):
Brain and central nervous system cancers
- adults
- consider an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks) to assess for brain or central nervous system cancer in adults with progressive, sub-acute loss of central neurological function
- children and young people
- consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer in children and young people with newly abnormal cerebellar or other central neurological function
Previous guidance (4) listed below was much more specific about different symptoms and when to refer:
Refer urgently patients with:
- symptoms related to the CNS in whom a brain tumour is suspected, including:
- progressive neurological deficit
- new-onset seizures
- headaches
- mental changes
- cranial nerve palsy
- unilateral sensorineural deafness
- 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)
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.
Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:
- subacute 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
Consider non-urgent referral or discussion with specialist for:
- unexplained headaches of recent onset:
- present for at least 1 month
- not accompanied by features suggestive of raised intracranial pressure.
Reference: