Document type: Clinical pathways
Place: Hertfordshire and West Essex ICB
Output type: Clinical Pathways
Pathway: Headache Pathway Tension Headache Trigeminal Neuralgia

Headache

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. NB: Suspected 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

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