When should I consider referring a patient with migraines to a specialist?

Consider referring a patient with migraines to a specialist if:

• The diagnosis of migraine is uncertain or atypical symptoms are present, such as motor weakness or poor balance.
• There is a suspicion of a serious underlying cause of headache (red flags), including sudden-onset headache, new neurological deficits, cognitive dysfunction, or recent head trauma.
• The patient has severe, uncontrolled status migrainosus lasting more than 72 hours.
• Optimal treatment in primary care does not adequately control symptoms, including consideration of medication overuse headache.
• Preventive treatment may be indicated but is not effectively managed in primary care.
• Young people with troublesome migraine that is non-responsive to trigger avoidance and simple analgesia.
• Pregnant or breastfeeding women with migraine requiring specialist input.
• Medication overuse headache is suspected, especially if the patient has been using triptans, opioids, ergots, or combination analgesics on 10 or more days per month, or paracetamol, aspirin, or NSAIDs on 15 or more days per month for 3 months or more.

Urgent referral or admission should be considered if a serious cause of headache is suspected or if status migrainosus is severe and uncontrolled. Specialist advice is also recommended if there are complications of migraine or if symptoms persist despite optimal primary care management.

Use of a headache diary and careful clinical review every 3 to 6 months is advised to monitor frequency, severity, and treatment response, with a low threshold for referral in young people and those with atypical or complicated presentations.

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