Presentation

First presentation of headache to clinician

If the history is suggestive of subarachnoid haemorrhage, meningitis or encephalitis, or there is papilloedema on fundoscopy or focal neurological signs on examination - contact medical team with a view for assessment.

Subarachnoid haemorrhage is characterised by a sudden, severe headache and may be associated with meningism, focal neurology or reduced GCS.
Meningitis - headache with photophobia, meningism and pyrexia/ signs of sepsis. Please remember presentation is varied and the immunocompromised and elderly may not be overtly meningitic.
Encephalitis - headache, seizures, change of behaviour, focal neurology and there may be pyrexia/signs of sepsis.

Assessment

  • Check blood pressure to ensure not due to hypertension.
  • Check CRP and plasma viscosity in those you suspect are at risk of temporal arteritis/ giant cell arteritis on basis of symptoms, past medical history and over age of 50yrs. If suspected please refer to the acute medical receiving team for assessment.
  • Refer optician for assessment in those who may have glaucoma or have optic discs which are difficult to visualise.
  • Environmental triggers - is patient sleeping well, keeping hydrated, eating regularly, drinking too much caffeine or alcohol or are they stressed?
  • Medication overuse - are they taking analgesics for headache more than 3 days per week? If yes advise to cut down and headache may worsens before it improves.
  • Request CT brain in those: over the age of 16, with a new headache or one whose character has changed, and if they fulfil the referral criteria below. NICE clinical Guideline 150 (endorsed by the Royal College of Radiologists) have listed symptoms which should prompt further investigation in patients with a headache.

CT brain referral criteria

Symptoms which would suggest a patient is at high risk of pathology and would be best seen as an in-patient/ ambulatory care unit referral:

  • worsening headache with fever
  • sudden-onset headache reaching maximum intensity within 5 minutes
  • new-onset neurological deficit
  • new-onset cognitive dysfunction
  • impaired level of consciousness

Symptoms which would suggest a moderate risk of pathology and an outpatient scan may be considered:

  • change in personality
  • 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)
  • 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

If criteria are met:

UseRADIOLOGY INTERACTIVE REFERRAL FORM. 
On request write 'outpatient headache pathway' and the reason the patient fulfills the criteria.

If assistance is required to interpret the scan or advice required to manage of headache email nhsh.neurology@nhs.scot

Episodic migraine

International Headache Society definition:
Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.
See:

Asking the patient to keep a headache diary can be useful to see if treatment has been effective

Trigeminal autonomic cephalalgias

Eg cluster, paroxysmal hemicrania, SUNCT, SUNA (groups of severe, stabbing, unilateral headache commonly in trigeminal distribution with autonomic features e.g. eye tearing, facial flushing etc). If description in keeping with IHS definition of paroxysmal hemicrania or hemicrania continua please give a trial of indomethacin to see if headache is eliminated. Prescribe INDOMETHACIN 75mg twice daily with a PPI for 3 weeks. If there is partial response it can be increased to up to 225mg daily. If not effective please stop.
Refer for neurology clinic appt. To discuss acute treatment before the appointment, call/ email nhsh.neurology@nhs.scot

International Headache Society definitions: https://www.ichd-3.org/3-trigeminal-autonomic-cephalalgias/
Cluster headache - ' Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to eight times a day. The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.'
Paroxysmal hemicrania - 'Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 2-30 minutes and occurring several or many times a day. The attacks are associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema. They respond absolutely to indomethacin.'
Short-lasting unilateral neuralgiform headache attacks (includes SUNCT/ SUNA) - 'Attacks of moderate or severe, strictly unilateral head pain lasting seconds to minutes, occurring at least once a day and usually associated with prominent lacrimation and redness of the ipsilateral eye.'
Hemicrania continua - ' Persistent, strictly unilateral headache, associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation. The headache is absolutely sensitive to indomethacin.'

Chronic daily headache

Most of these are: tension headache, chronic migraine or medication overuse headache. It is possible to have two chronic headache conditions simultaneously. If the headache does not fit this history a referral and further imaging should be considered.

Headache diary
Consider trial of amitriptyline, topiramate, gabapentin

Definitions:

Chronic tension type headache Diagnostic criteria: 

  1. Headache occurring 15 days/month for >3 months
  2. Lasting hours to days, or unremitting   
  3. At least two of the following four characteristics:
    1. bilateral location
    2. pressing or tightening (non-pulsating) quality
    3. mild or moderate intensity
    4. not aggravated by routine physical activity such as walking or climbing stairs
      And both of the following:
    5. no more than one of photophobia, phonophobia or mild nausea
    6. neither moderate or severe nausea nor vomiting

       D. No other cause more likely

Chronic migraine - Headache occurring on 15 or more days per month for more than three months, which, on at least 8 days per month, has the features of migraine headache.
Diagnostic criteria: For chronic migraine needs to fulfil criteria A to D.

  1. Headache (migraine-like or tension-type-like) 15 days/month for >3 months
  2. Occurring in a patient who has had at least five attacks of headache lasting 4-72 hours (untreated)
  3. Character of headache (needs 2 or more)-
    1. unilateral location
    2. pulsating quality
    3. moderate or severe pain intensity
    4. aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
    5. During headache at least one of the following:
    6. nausea and/or vomiting
    7. photophobia and phonophobia

      D. No other cause more likely

Medication overuse headache-as headache which is present for ≥ 15 days per month, and which has developed or worsened during regular overuse for > 3 months of one or more acute headache drugs (any analgesic but triptans and opiates are the worst offenders.)

Headache induced by a cough, bending forward, defaecating or exercise

Many headaches can be worsened by these activities. But if it causes a headache the patient will be assessed in clinic and considered for an MRI.

Glossary

AbbreviationMeaning
GCSGlasgow Coma Scale
CTComputed tomography scan
SUNCTShort-lasting unilateral neuralgiform headache with conjunctival injection and tearing 
SUNAShort lasting unilateral neuralgiform headache attacks
PPIProton pump inhibitors 
IHSInternational Headache Society

Editorial Information

Last reviewed: 05/07/2021

Next review date: 05/07/2024

Author(s): Neurology Department .

Approved By: TAM Subgroup of ADTC

Reviewer name(s): Consultant Neurologist.

Document Id: TAM278