NICE summary - headache (features when it is suggested that investigation or referral is required in children 12 years or older and adults)

Last edited 05/2019 and last reviewed 12/2021

Assessment of headaches:

Summary points from NICE are(1):

Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral:

• 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

The two week referral criteria for a suspected brain tumour is linked below.

Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.

Consider using a headache diary to aid the diagnosis of primary headaches

If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:

• frequency, duration and severity of headaches
• any associated symptoms
• all prescribed and over the counter medications taken to relieve headaches
• possible precipitants
• if female and of having periods - relationship of headaches to menstruation

Reference:

• NICE (November 2015). Headaches - Diagnosis and management of headaches in young people and adults