Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Headache PathwayTension HeadacheTrigeminal Neuralgia


Please refer to the full pathway

Following appropriate history and examination, determination of the following should be made:

Rule out Red Flags (check pathway) – require emergency referral.  NBSuspected Giant cell arteritis – requires call to Rheumatologist/Medical registrar/consultant on call and other immediate action, Symptoms and signs of acute narrow-angle closure glaucoma – Red eye and haloes around lights – immediate ophthalmology referral                                                                                                                               

Suspected brain tumour - check referral criteria. urgent two week wait referral  (refer using the 2 week wait form).  NB: cancer is very unlikely in headache.  Generally, only first presentation of headache with features that would suggest raised intracrainial pressure would meet referral criteria.

If the headache does not fall into the above categories, determine if it is the following and manage as per the flowchart (and associated pathways specified) in the full guideline:

First rule out common primary headache

  • Migraine (with/without aura) - (refer to the Migraine with/without aura pathway)
  • Tension headache - (refer to the Tension headache pathway)

If none of the above consider common secondary cause of headache

  • Medication overuse headache
  • Acute sinusitis
  • Other causes including cervical spondylosis

If none of thre above consider less common cause of headache

  • Trigeminal neuralgia - (refer to the Trigeminal neuralgia pathway)
  • Cluster headaches - (refer to neurology)

If none of the above cause of headache difficult to determine

  • Consider more than one type or a mixed presentation of headache
  • Commence headache diary (provided in the tabs on the left)
  • Refer to Neurology - consider advice and guidance (see below)

Advice and Guidance service - can be used for advice on non-emergency headache queries including:

  • Diagnostic uncertainty despite primary care investigation and management  
  • Medication advice for headaches when first line medications have been exhausted
  • New presentation of suspected cluster headaches
  • Exertional/coital headaches

Neurology referrals

  • For urgent advice discuss with Neurologist (or acute medical team if unable to contact consultant neurologist)
  • Routine referrals: please use choose and book system/e-referral