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The following diagram gives an overview of the primary care pathway (through to the interface with secondary care) based on presentation at General Practice.
Most patients presenting to health services with headaches have primary headache (up to 95% presenting to primary care and over 50% presenting to A&E). The most common primary headache is migraine, making up the majority of these patients. Most patients with migraine can be adequately managed in primary care. Some patients, particularly those with more frequent headache may need input from secondary care.
The following diagram lists the important red, amber and green flags:
Most patients do not have serious secondary headache. Red flags indicate the need for urgent assessment to exclude a secondary cause. The most consistent indicators for serious secondary causes for headache are:
Thunderclap headache is usually occipital or global. It is defined as a severe abrupt onset headache, usually reaching its peak instantaneously, but headache can progress over up to 5 minutes. The main consideration is subarachnoid haemorrhage, but other causes include cervical artery dissection, intracranial haemorrhage, posterior circulation stroke, cerebral venous sinus thrombosis and spontaneous intracranial hypotension.
Anyone presenting with a thunderclap headache should have a same day referral (which may be through A&E), even in delayed presentations.
A new focal neurological symptom (eg seizure) or sign (eg hemiparesis) in a patient with a new progressive headache indicates the possibility of an intracranial pathology and this should prompt an urgent referral for assessment and appropriate imaging. The referring clinical should decide whether this merits attendance at A&E, a call to the appropriate specialist service or an urgent referral. Specific syndromes that may indicate the possibility of a brain tumour are listed below, but extra dural / sub dural haematomas, cerebral venous sinus thrombosis, viral encephalitis and other intracranial pathology can present similarly.
Fever, neck stiffness and rash should raise the consideration of infection such as meningitis and constitutional symptoms and scalp tenderness should raise the consideration of Giant Cell Arteritis (GCA).
Most headache in older patients will have a benign cause (mainly migraine), but the clinician should have a lower threshold for considering a secondary cause in an older patient with a new persisting or worsening headache. Anyone over 50 with a new headache should have a CRP +/- plasma viscosity +/- ESR + FBC as per local protocol to consider GCA. Anyone where this is a serious consideration should have an urgent referral and consideration of steroids as per local protocol.
Features that may indicate a secondary cause but may also be seen in primary headaches:
Consider a secondary cause if any of these are present.
Orthostatic headache should have a consistent onset / worsening on assuming an upright posture and offset / significant improvement on lying flat. This should be differentiated from headache which improves on lying still, which is a feature of migraine. Early assessment and treatment of Spontaneous Intracranial Hypotension (SIH) improves outcomes and patients with orthostatic headache should be referred urgently. Further information is available in the consensus guidelines on SIH.
Headache wakening the patient, headache present on wakening which then improves after assuming an upright posture and Valsalva headache (headache triggered by coughing or other Valsalva manoeuvres) raises the possibility of raised intracranial pressure. Headache present on wakening which improves after assuming an upright posture may also be due to cervicogenic headache and obstructive sleep apnoea or other causes of nocturnal hypoventilation. Migraine starting in sleep is the commonest cause for wakening with a headache (especially if the headache is intermittent). It is also important to consider Medication Overuse Headache as
“wearing off” of the overused medication during sleep can result in wakening with a headache which then improves with taking the overused medication. These patients are likely to have migraine.
Normal imaging does not exclude raised intracranial pressure and it is important to examine the patient for papilloedema. An urgent optician assessment should be considered where the clinician is not confident undertaking ophthalmoscopy. More detail on the assessment and management of Intracranial Hypertension can be found on (insert link). Due to risk to vision, patients should be referred same day as per local protocol, usually to ophthalmology in the first instance.
A history of cancer, immunosuppression (including HIV) and recent head trauma in a patient with new progressive headache should raise the consideration of secondary brain tumour, infection or intracranial haemorrhage. These patients usually have other features in addition to headache.
Features that do not help to differentiate primary from secondary headaches are:
Features that are supportive of a diagnosis of primary headache:
If there are no concerning features then it is appropriate to manage these patients for migraine.
Other features that are pointers to migraine include a previous migraine history and a family history of migraine.
Migraine is the commonest primary headache presenting to both primary and secondary care. It is however important to consider other primary headache disorders as per the following table.
Please note that this table may require both horizontal and vertical scrolling to view all content in the mobile app version.
| Headache feature | Migraine (with or without aura) | Cluster headache | Tension-type headache |
| Frequency | Majority of patients presenting to both primary and secondary care (94% of people presenting in primary care with episodic headache will have migraine) | Rare - 1 in 1,000 | Very common, but not often seen in primary or secondary care as usually mild and self-managed |
| Duration of headache |
4 – 72 hours in adults 1 – 72 hours in young people |
15 minutes to 3 hours | 30 minutes – continuous |
| Pain location |
Unilateral or bilateral (head, face or neck) |
Unilateral (around the eye, above the eye and along the side of the head/face) |
Bilateral (head, face or neck) |
| Pain quality |
Pulsating (throbbing or banging in young people) |
Variable (can be sharp, boring, burning, throbbing or tightening) |
Pressing/tightening (non-pulsating) |
| Pain intensity | Moderate or severe | Severe or very severe | Mild or moderate |
| Effect of activities |
Aggravated by, or causes avoidance of, routine activities of daily living (e.g. prefer to stay still or go to bed) |
Restlessness or agitation | Not aggravated by routine activities of daily living |
| Other symptoms |
|
Cranial autonomic symptoms on the same side as the headache:
Patients with cluster can get migrainous symptoms and aura |
None |
Migraine is differentiated into episodic and chronic migraine
Patients with episodic have migraine on 14 or less days per month (high frequency episodic migraine 10-14 days per month).
Patients with chronic migraine have 15 or more days of headache per month 8 of which should meet criteria for migraine. Chronic migraine therefore usually presents with a mixture of milder background headache and migraine.
Migraine is the most likely diagnosis for a patient attending primary care with headache. Many of these patients will be successfully managed in primary care. If there is a clear diagnosis of migraine we recommend acute +/- preventative treatment (as detailed in the acute and preventative treatment sections).
Where preventative treatment is not successful after a trial of three preventative medications at an adequate dose and for an adequate length of time, consider referral to relevant secondary care services as per local arrangements.
If there is diagnostic uncertainty or concern about a secondary cause, consider open access CT as an alternative to secondary care referral.
Patients should be directed to the resources available on NHS Inform to for lifestyle advice. Where consultation time allows the following key points should be made in relation to lifestyle.
Manage potential triggers as needed; e.g. avoid perfumes, certain food triggers if applicable, bright, flashing or flickering lights (consider wearing sunglasses when outside or in bright, flashing or flickering light)
Further advice is available from the Migraine Trust on 0808 802 0066 or https://migrainetrust.org/what-we-do/our-information-and-support-service/
@NHSScotCfSD
Centre for Sustainable Delivery
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