Approach to headache in primary care, including red flags needing urgent referra

Approach to managing headache in primary care

• Evaluate the person presenting with headache for any red flags or features suggestive of a serious underlying cause, such as sudden onset reaching maximum intensity within 5 minutes, new neurological deficits, or symptoms suggestive of conditions like giant cell arteritis or acute narrow angle glaucoma. If red flags are present, urgent referral or specialist assessment is necessary ².
• Use a headache diary to aid diagnosis, recording frequency, duration, severity, associated symptoms, precipitants, and relationship to menstruation over at least 8 weeks ².
• Diagnose tension-type headache, migraine (with or without aura), or cluster headache based on characteristic features, including pain location, quality, intensity, and associated symptoms ².
• For persistent symptoms despite treatment, check drug adherence, maximum tolerated doses, and consider medication overuse headache. Reassess for alternative diagnoses and seek specialist advice if diagnosis is uncertain or symptoms are atypical ².
• In cases of red flags or suspicion of secondary headache, arrange urgent specialist assessment or neuroimaging, such as a non-contrast CT scan within 6 hours of symptom onset for suspected subarachnoid haemorrhage, and consider lumbar puncture if initial imaging is inconclusive ⁵.
• For specific headache types like cluster headache, if red flags or serious underlying causes are suspected, arrange specialist referral or admission depending on clinical judgment. Confirm diagnosis with specialist assessment, and manage acute attacks according to specialist advice ⁴.

Identification of red flags necessitating urgent referral

• Sudden-onset headache reaching maximum intensity within 5 minutes (thunderclap headache) ².
• New neurological deficits, cognitive dysfunction, or change in personality ².
• Headache triggered by cough, Valsalva, sneeze, or exercise, or orthostatic headache ².
• Symptoms suggestive of serious conditions such as giant cell arteritis or acute narrow angle glaucoma ².
• Recent head trauma or a substantial change in headache characteristics ².
• Signs of possible subarachnoid haemorrhage, such as neck stiffness, photophobia, nausea, vomiting, or altered consciousness ⁵.