REMEDY : BNSSG referral pathways

Chronic Headache and Migraine in Adults

Checked: 05-10-2018 by vicky.ryan Next Review: 04-10-2019

Principles of Management

Chronic headache and migraine can usually be managed in primary care after appropriate safety netting (see red flag section below).

There are numerous guidelines and pathways available both locally and nationally which can make management confusing for GPs. A useful starting point for guidance on diagnosis is the Clinical Knowledge Summary chapter on Headache assessment. The diagnosis section of the  BASH guidelines is also useful and easy to read.

Diagnosis table for tension-type headache, migraine and cluster headache from the NICE website (CG150) is attached.NICE Headache diagnosis table (PDF)

Migraine is the most common severe form of primary headache with a global prevalence of around 1 in 7 people. There are useful guidelines recently updated by SIGN on the Pharmacological management of migraine.

The Chronic Headache Care Pathway was developed locally in September 2007. They have been updated since, most recently in 2016 so please ignore the dates on the documents. Please refer to the below links to access these guidelines:

Chronic Headache care pathway - full

Chronic Headache care pathway - quick reference

Specialist Advice

This presentation (powerpoint) was made by Dr Luke Bennetto, Consultant Neurologist at NBT, during the Neurology Education Session in June 2012.  It contains hints, tips and other information that may help primary care clinicians manage patients with headache.

Useful Links

Clinical Knowledge Summaries provides advice on various aspects of headache assessment and management:

Headache assessment

Migraine

Medication overuse headache

Cluster headache 

Tension-type headache

SIGN provides information on the diagnosis and management of headache in adults including: primary headache disorders, secondary headache and chronic headache. Their headache guidelines were last updated in 2008:

Diagnosis and management of headache in adults

Exeter Headache Clinic is run by a GPSI with a special interest in headache.  It is a primary care based service and receives referrals from the whole of Devon for headache >6 months.  The website provides effective guidelines and pathways:

Exeter Headache Clinic (web page)

Headache - Who Should be Investigated for Brain Tumour in Primary Care? (PDF)

British Association for the Study of Headache (BASH) is a national member of the International Headache Society.  It provides links to news, research and guidelines; provides training courses for any interested physician; and consults on national policy issues. Their headache guidelines were last updated in 2010:

BASH guidelines.

 

 

 

 

 

 

Red Flags

Clinical knowledge summaries has a list of red flags that may indicate a serious cause of headache that may require emergency or urgent referral.

Please also see the Brain and CNS suspect cancer guidelines for advice on referral criteria for brain tumours and how to refer.

Referral

If management of headache in primary care is not successful then referral to secondary care neurology clinic may be considered.

SIGN guidelines suggest that referral to secondary care for migraine should be considered if 3 or more therapies in primary care have failed. 

Referrals should be submitted via eReferral.

Home oxygen for Cluster Headaches

A pathway for treatment of cluster headaches is currently undergoing consultation and will be published here when available.