Headache is one of the commonest reasons for referrals to neurology. Before making a referral for headache, please consult the text below for advice on management, and when, how and whether referral is required.
For Headache where there is a suspicion of brain cancer/tumour (e.g. cognitive changes, Cancer/HIV, focal signs, LOC..etc), please refer to this page Radiology> Headache Suspicious of Cancer
M. A & R.D 07-05-25
Referral to Neurology for chronic headache – local guidance
6 questions to consider before referral:
- Could the main issue be migraine? Over 95% of headache referrals relate to migraine with or without some tension type headache. Looking for migraine is helpful as then you can try migraine treatments even if there is more non specific headache at other times. Look for episodes when headache worsens, becomes throbbing and/or makes the person want to lie down somewhere dark and quiet.
- CT head? Do you want a clinical opinion or a CT head scan? – if just the latter then NHS Lothian provides open access CT head. Remember, incidental finding (10%) vs. relevant finding (<0.5%), radiation dose is over 100 chest x-rays and studies suggest it doesn’t provide long-lasting reassurance
- Acute Treatments for Migraine (see below links for more detail) – have you tried soluble Aspirin 900mg, Sumatriptan 100mg, Almotriptan 12.5mg, rizatriptan 10mg with anti-emetics? If severe vomiting, try subcutaneous Sumatriptan 6mg. You can try Rimegepant 75mg if the patient cant tolerate triptans or has failed two triptans (see migraine page) Migraine/Chronic Headache – RefHelp
- Preventative Treatment for migraine (see below links for more detail) – have you tried a Beta-blocker (eg Propanolol), a Tricyclic (eg Nortriptyline) Candesartan or, if those have been tried, Atogepant at therapeutic doses for 3-4 months each. See migraine page Migraine/Chronic Headache – RefHelp
- Treatment of Medication Overuse Headache – Stop regular analgesia (especially codeine) and limit acute treatment to 10x/month. Tell the patient they will feel worse for a while and wait for 3-4 weeks before expecting any benefit
- Tackle insomnia and fatigue – Many patients with chronic daily headache also have insomnia and fatigue. Improving other causes of these symptoms can improve headache.+
Pathway Information
- Migraine/Chronic Headache
- Headache as a new complaint including adult assessment
- Guide to differentiating primary headache disorders
Referral to Neurology
Referral via the ‘Chronic Headache’ pathway on SCI gateway is appropriate for patients who been through all the steps above including Atogepant, if chronic migraine for a period of 3 months each at therapeutic doses
Headache Relief Guide – useful resource especially for younger people Home | Headache Relief Guide
