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Neurological

Headache - assessment

Last revised in March 2022

Headache is a common symptom associated with many conditions.

Headache - assessment: Summary

  • Headache is a common symptom associated with many clinical conditions. The International Classification of Headache Disorders (ICHD) categorizes headache into:
    • Primary headaches (majority) — not associated with an underlying condition, includes migraine, tension-type headache, and trigeminal autonomic cephalgias (including cluster headache).
    • Secondary headaches — precipitated by another condition or disorder (local or systemic), such as head or neck trauma; cranial or cervical vascular disorders including stroke and temporal arteritis; central nervous system (CNS) malignancy; exposure to or withdrawal from a substance including medication overuse headache; infection (intracranial or systemic); disorders of facial or cranial structures, such as the eyes, ears, sinuses, or teeth; and psychiatric disorders.
    • Painful cranial neuropathies, other facial pains, and other headaches including trigeminal neuralgia and post-herpetic neuralgia.
  • Headache is among the most common neurological reason for attending emergency departments in the UK.
  • Assessment of a person with headache should include asking about:
    • Red flags suggesting a serious secondary cause needing specialist assessment.
    • The onset, duration, frequency, pattern, and characteristics of pain including location, severity, and quality.
    • Associated symptoms such as aura; nausea and vomiting; motion sensitivity; photophobia and/or phonophobia (may suggest migraine).
    • Autonomic features such as lacrimation, conjunctival injection, rhinorrhoea (may suggest cluster headache).
    • Predisposing, trigger, or relieving factors such as trauma, posture, Valsalva manoeuvre, menstrual cycle, and medication or other substances including caffeine and alcohol.
    • Comorbidities including malignancy and immunosuppression.
    • Medications for symptom relief (including ergotamines, triptans, opioids, combination analgesia, and simple analgesia which may cause medication overuse headache).
    • The impact on daily activities and quality of life.
  • Examination of a person with headache should include:
    • Checking vital signs; mental state and alertness; the neck, facial, and extracranial structures; and neurological examination including fundoscopy.
  • Emergency admission or urgent referral should be arranged, depending on clinical judgement, if there are any red flags or a serious underlying cause of secondary headache is suspected.
  • Further assessment in primary care with a headache diary for at least 8 weeks should be considered in primary care if:
    • The primary diagnosis is uncertain but a secondary cause has been excluded. Investigations are generally not needed to diagnose a primary headache.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the assessment of adults presenting with undiagnosed headache. It provides diagnostic criteria for the common primary headache disorders and for medication overuse headache, and describes clinical features that may indicate serious underlying pathology causing a secondary headache disorder, requiring specialist admission or referral.

This CKS topic does not cover the management of specific headache disorders, such as tension-type headache, migraine, cluster headache, and medication overuse headache.

There are separate CKS topics on Carbon monoxide poisoning, Giant cell arteritis, Headache - cluster, Headache - medication overuse, Headache - tension-type, Migraine, Neck pain - acute torticollis, Neck pain - cervical radiculopathy, Neck pain - non-specific, Otitis media - acute, Otitis media with effusion, Post-herpetic neuralgia, Shingles, Sinusitis, Temporomandibular disorders (TMDs), and Trigeminal neuralgia.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

March 2022 — reviewed. A literature search was conducted in February 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. The topic has been updated in line with current available literature. The sections on Prognosis, Complications, and Differential diagnosis have been deleted, as content is included elsewhere in this topic or in other CKS topics. No major changes to the clinical recommendations have been made.

Previous changes

August 2020 — minor update. Assessment section renamed 'Diagnosis'.

October 2019 — minor update. Expert neurosurgical opinion on the presentation of sudden acute severe headache has been added to the 'Red Flags' section. 

October 2017 — revised. A literature search was conducted in August 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. No major changes to clinical recommendations have been made.

October 2012 to May 2013 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. This search identified two major guidelines produced by the National Institute for Health and Care Excellence (NICE) and the British Association for the Study of Headache (BASH). Only minor changes to the previous CKS topic were required to ensure compatibility with recommendations made by NICE and BASH.

March to August 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

September 2008 — minor correction to the Changes section. Issued in September 2008.

October 2005 — minor technical update. Issued in November 2005.

July 2005 — update to text discussing nonsteroidal anti-inflammatory drugs (NSAIDs) in the Medicines management and Prescribing information sections. Issued in July 2005.

January 2005 — rewritten. Validated in March 2005 and issued in April 2005.

December 2001 — reviewed. Validated in March 2002 and issued in April 2002.

October 2000 — updated to incorporate the Department of Health (DOH) Referral guidelines for suspected brain tumour and suspected children's cancer.

October 1998 — written.

Update

New evidence

Evidence-based guidelines

  • NICE (2025) Headache in over 12s: diagnosis and management. National Institute for Health and Care Excellence. [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2022.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 March 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2022.

New policies

No new national policies or guidelines since 1 March 2022.

New safety alerts

No new safety alerts since 1 March 2022.

Changes in product availability

No changes in product availability since 1 March 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Assess a person with headache presenting in primary care.
  • Identify a person with a potentially serious cause for secondary headache and arrange specialist admission or referral as appropriate.
  • Identify a person with a primary headache disorder or medication overuse headache that can usually be managed in primary care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

The following NICE quality standards are relevant for this CKS topic:

  • Statement 1. People diagnosed with a primary headache disorder have their headache type classified as part of the diagnosis.
  • Statement 2. People with a primary headache disorder are given information on the risk of medication overuse headache.
  • Statement 3. People with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.
  • Statement 4. People with migraine are advised to take combination therapy with a triptan and either a nonsteroidal anti-inflammatory drug (NSAID) or paracetamol.

[NICE, 2013]

 

Background information

What is it?

  • Headache is a common symptom associated with many clinical conditions. The International Classification of Headache Disorders (ICHD) categorizes headache into [IHS, 2018] [Ahmed, 2019]:
    • Primary headaches — these account for the majority of headaches, and are not associated with another underlying condition, such as:
      • Migraine (global lifetime prevalence 10% in men; 22% in women). See the CKS topic on Migraine for more information.
      • Tension-type headache (mean global lifetime prevalence 42%). See the CKS topic on Headache - tension-type for more information.
      • Trigeminal autonomic cephalgias — including cluster headache (prevalence of about 0.1%), paroxysmal hemicrania, and hemicrania continua. See the CKS topic on Headache - cluster for more information.
      • Other — such as primary cough or exercise headache or cold-stimulus headache.
    • Secondary headaches — these are precipitated by another condition or disorder (local or systemic), such as:
    • Painful cranial neuropathies, other facial pains, and other headaches — includes conditions such as trigeminal neuralgia, post-herpetic neuralgia, and optic neuritis. See the CKS topics on Post-herpetic neuralgia and Trigeminal neuralgia for more information.

How common is it?

Headache is among the most common neurological reasons for attending Emergency departments in the UK [NHS RightCare, 2019].

  • Headache is the commonest symptom reported in the general population, with a lifetime prevalence of more than 90% [Latinovic, 2006].
    • A cross-sectional study with modified cluster sampling using structured questionnaires (n = 8271 from 10 European countries) found [Steiner, 2014]:
      • The unadjusted lifetime prevalence of headache was 91.3%.
      • The annual prevalence of headache was 78.6%.
  • Most people self-manage their headaches, but it remains a common reason for primary care consultation [Underwood, 2017].
    • A UK retrospective primary care observational study of patient data from 253 general practices (n = 13,228,430 patient-years at risk) found [Latinovic, 2006]:
      • The annual primary care consultation rate for headache was 6.4 per 100 female patients, and 2.5 per 100 male patients.
      • Consultation rates peaked in the 15–24 years age group, and declined with age.
      • The referral rate to neurology was 2.1 per 100 patients, and was highest in the 55–64 years age group.

Diagnosis

Scenario: Headache - diagnosis

From age 16 years onwards.

How should I assess a person presenting with headache?

If a person presents with headache in primary care, assessment of clinical features allows the specific International Classification of Headache Disorders ICHD diagnostic criteria to be used, to accurately diagnose the type of headache(s). Assessment should include exclusion of red flags suggesting a serious underlying cause, which needs specialist admission or referral.

Ask about:

  • The onset, duration, frequency, and temporal pattern (episodic, daily, and/or unremitting) of headache.
  • The characteristics of pain including location and spread, severity, nature, and quality.
  • Any associated symptoms such as:
    • Aura (fully reversible visual and/or sensory and/or speech disturbance evolving over minutes with a total duration of up to 60 minutes) — may suggest a diagnosis of migraine.
    • Nausea, vomiting, motion sensitivity, photophobia, and/or phonophobia (noise intolerance) — may suggest a diagnosis of migraine.
    • Autonomic features such as lacrimation (eye tearing), conjunctival injection, eyelid swelling or drooping, nasal congestion, or rhinorrhoea — may suggest a diagnosis of cluster headache if ipsilateral to the pain (but can also occur in migraine).
    • Symptoms of systemic illness such as fever and/or neurological deficit such as limb weakness or visual disturbance. See the section on Red flags for more information.
    • Note: tension-type headache does not typically have associated symptoms.
  • Any household contacts with similar symptoms — may suggest a diagnosis of carbon monoxide poisoning. See the topic on Carbon monoxide poisoning for more information. 
  • Any predisposing, trigger, and relieving factors such as trauma, posture, Valsalva manoeuvre (such as coughing, sneezing, bending, or exertion), fatigue or stress, menstrual cycle, or medication or substance change(s) or withdrawal including caffeine or alcohol.
  • Any comorbidities including conditions leading to immunocompromised, systemic illness, malignancy, anxiety, depression, insomnia, or pregnancy.
  • Any family history of similar headache.
  • Any medications used for symptom relief (such as ergotamines, triptans, opioids, simple analgesia) and over-the-counter medications, including days used per month and symptom response. Any recreational drugs (including cocaine and opioids).
  • The impact on daily activities and quality of life.
    • Avoidance of physical activity and a preference to stay still during an attack may suggest a diagnosis of migraine.
    • Associated agitation or restlessness during an attack may suggest a diagnosis of cluster headache.
    • Tension-type headache typically has no impact on activities.

Examine the person:

  • Vital signs — assess blood pressure, pulse, respiration rate, temperature, and oxygen saturation levels.
  • General appearance and mental state — assess for signs of a serious underlying cause, including non-blanching skin rash, reduced level of consciousness, or confusion.
  • Extracranial structures — assess the carotid arteries, temporal arteries, sinuses, and temporomandibular joints. See the CKS topics on Giant cell arteritis, Sinusitis, and Temporomandibular disorders (TMDs) for more information.
  • The neck — assess for meningeal irritation, tenderness of cervical paraspinal muscles, range of movement, and crepitation. See the CKS topics on Meningitis - bacterial meningitis and meningococcal disease, Neck pain - acute torticollis, Neck pain - cervical radiculopathy, and Neck pain - non-specific for more information.
  • Fundoscopy — assess for papilloedema, pupillary asymmetry and reactivity.
  • Neurological examination — assess cranial and peripheral nerves including gait.
    • If there are new focal neurological signs, arrange specialist admission or referral, the urgency depending on clinical judgement.
    • If the neurological examination is normal and clinical features suggest a primary headache disorder, there is no increased risk of a secondary precipitant and referral is not needed.

Consider arranging investigations, depending on the likely underlying cause and clinical judgement.

  • If there are any red flags or a serious underlying cause of secondary headache is suspected, arrange specialist admission or referral, the urgency depending on clinical judgement.
  • Investigations are generally not needed to diagnose a primary headache.
    • If the primary diagnosis is uncertain but a secondary cause has been excluded, consider using a headache diary and/or quality of life assessment tool to measure the frequency, duration, severity, triggers, medications used, and impact of headache for at least 8 weeks. The British Association for the Study of Headache (BASH, website www.bash.org.uk) has useful Headache diary and QOL measurement tools.
    • If the diagnosis remains uncertain, consider seeking specialist advice or arranging neurology referral, the urgency depending on the likely underlying cause and clinical judgement.

Red flags

Serious causes of secondary headache are rare, accounting for less than 1% of people presenting with headache [Steiner, 2019]. Red flags suggesting a potentially serious cause of secondary headache requiring emergency admission or urgent specialist referral include [Ahmed, 2019] [Do, 2019] [Steiner, 2019] [NICE, 2021a]:

  • New severe or unexpected headache.
  • Progressive or persistent headache, or headache that has changed dramatically.
    • If there is evolution of headache over days to weeks, particularly with focal neurological signs, consider a space-occupying lesion or subdural haematoma. See the CKS topic on Head and neck cancers - recognition and referral for more information.
  • Associated features such as:
    • Fever, impaired consciousness, seizure, neck pain/stiffness, or photophobia may indicate central nervous system (CNS) infection such as meningitis or encephalitis; neck stiffness may indicate subarachnoid haemorrhage. See the CKS topic on Meningitis - bacterial meningitis and meningococcal disease for more information. 
    • Papilloedema may indicate a space-occupying lesion, cerebral venous sinus thrombosis, or benign intracranial hypertension. See the CKS topic on Head and neck cancers - recognition and referral for more information.
    • New-onset focal neurological deficit, change in personality, cognitive impairment, and/or altered consciousness may indicate a stroke or transient ischaemic attack (TIA), malignancy, CNS infection, or other cause of space-occupying lesion such as subacute or chronic subdural haematoma. See the CKS topics on Stroke and TIA, Head and neck cancers - recognition and referral, and Meningitis - bacterial meningitis and meningococcal disease for more information.  
    • Atypical aura (duration greater 60 minutes, or including motor weakness, double vision, visual symptoms affecting only one eye, or impaired balance) or aura occurring for the first time in a person using the combined oral contraceptive (COC) pill — consider a stroke or TIA. See the CKS topics on Stroke and TIA and Contraception - combined hormonal methods for more information.
    • Dizziness — consider an ischaemic or haemorrhagic stroke. See the CKS topic on Stroke and TIA for more information.
    • Visual disturbance — can be associated with migraine but also with serious causes such as angle-closure glaucoma and temporal arteritis. See the CKS topics on Glaucoma and Giant cell arteritis for more information.
    • Vomiting — can be associated with migraine but also with serious causes such as a mass lesion including brain abscess or carbon monoxide poisoning. See the CKS topics on Head and neck cancers - recognition and referral and Carbon monoxide poisoning for more information.
  • Contacts with similar symptoms.
    • Consider serious causes such as carbon monoxide poisoning. See the CKS topic on Carbon monoxide poisoning for more information.
  • Precipitating factors such as:
    • Preceding recent head trauma (usually within the past 3 months) — consider subacute or chronic subdural haematoma.
    • Headache triggered by a Valsalva manoeuvre (such as coughing, sneezing, bending, or exertion) — consider a Chiari malformation type 1 (a herniation of the cerebellar tonsils), a posterior fossa lesion, or other space-occupying lesions.
    • Headache that worsens on standing — consider a cerebrospinal fluid leak.
    • Headache that worsens on lying down — consider a space-occupying lesion or cerebral venous sinus thrombosis. See the CKS topic on Head and neck cancers - recognition and referral for more information.
  • Comorbidities such as:
  • Current or recent pregnancy.

ICHD diagnostic criteria

Detailed diagnostic criteria for all headache disorders, including less common subtypes, are available from the International Headache Society (IHS) 2018 publication 'International Classification of Headache Disorders, 3rd edition' (ICHD-3). The ICHD criteria for common headache disorders include:

Migraine without aura
  • At least five attacks fulfilling the following criteria:
    • Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated).
    • The headache has at least two of the following four characteristics:
      • Unilateral location.
      • Pulsating quality.
      • Moderate or severe pain intensity.
      • Aggravation by, or causing avoidance of, routine physical activity (such as walking or climbing stairs).
    • During the headache at least one of the following:
      • Nausea and/or vomiting.
      • Photophobia.
      • Phonophobia.
  • See the CKS topic on Migraine for more information.
Migraine with aura
  • At least two attacks fulfilling the following criteria:
    • One or more of the following fully reversible aura symptoms:
      • Visual symptoms such as zigzag lines, flickering lights, and/or scotoma (visual aura is the most common type of aura).
      • Sensory symptoms such as numbness or pins and needles of the hand, arm, and/or face.
      • Speech and/or language disturbance such as aphasia.
      • Motor weakness (rare).
      • Brainstem symptoms such as vertigo, diplopia, tinnitus, ataxia.
      • Retinal symptoms such as monocular scintillations or scotoma.
    • At least two of the following four characteristics:
      • At least one aura symptom spreads gradually over at least 5 minutes, and/or two or more symptoms occur in succession.
      • Each individual aura symptom lasts 5–60 minutes.
      • At least one aura symptom is unilateral.
      • The aura is accompanied, or followed within 60 minutes, by headache.
  • See the CKS topic on Migraine for more information.
Tension-type headache
  • Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting. The headache may also be associated with no more than one of photophobia or phonophobia, and
  • The headache has at least two of:
    • Bilateral location.
    • Pressing, tightening, non-pulsating quality.
    • Mild or moderate intensity.
    • Not aggravated by routine physical activity (such as walking or climbing stairs).
  • See the CKS topic on Headache - Tension-type for more information. 
Cluster headache
  • At least five attacks of severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes (untreated), and
  • The headache is associated with a sense of restlessness or agitation and/or at least one of the following ipsilateral to the headache:
    • Conjunctival injection and/or lacrimation.
    • Nasal congestion and/or rhinorrhoea.
    • Eyelid swelling.
    • Forehead and facial sweating.
    • Forehead and facial flushing.
    • Sensation of fullness in the ear.
    • Miosis (excessive pupillary constriction) and/or ptosis.
  • Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active. Note: the British Association for the Study of Headache (BASH) guideline states a frequency of 1–3 attacks per day (up to 8) and usually occur daily for 2–3 months at a time [Ahmed, 2019].
  • See the CKS topic on Headache - cluster for more information.
Medication overuse headache
  • Headache occurring on at least 15 days per month for at least 3 months, with a pre-existing headache disorder (typically a predisposition to migraine and/or tension-type headache).
  • Regularly overused, for more than 3 months, one or more drugs that can be taken for acute and/or symptomatic treatment of headache such as ergotamines, triptans, simple analgesics, or opioids.
  • The BASH guideline states ergotamines, triptans, combination analgesics, or opioids taken on 10 or more days per month, or 15 days for simple analgesics such as paracetamol, aspirin, or a nonsteroidal anti-inflammatory drug (NSAID), for more than 3 months [Ahmed, 2019].
  • See the CKS topic on Headache - medication overuse for more information. 

[IHS, 2018; Ahmed, 2019; NICE, 2021b]

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) guideline Headache in over 12s: diagnosis and management [NICE, 2021b], the British Association for the Study of Headache (BASH) guideline National headache management system for adults [Ahmed, 2019], the International Headache Society (IHS) publication The International Classification of Headache Disorders, 3rd edition [IHS, 2018], the European Headache Federation (EHF) joint publication Aids to management of headache disorders in primary care (2nd edition) [Steiner, 2019] and the EHF consensus document European Headache Federation consensus on technical investigation for primary headache disorders [Mitsikostas, 2015], the joint NHS RightCare publication RightCare: headache and migraine toolkit optimising a headache and migraine system [NHS RightCare, 2019], and expert opinion in a review article on orange and red flags for secondary headache [Do, 2019].

Assessing for red flags
  • The recommendation to assess for red flags is based on the NICE guideline [NICE, 2021b], the BASH guideline [Ahmed, 2019], the EHF joint publication [Steiner, 2019], and expert opinion in a review article [Do, 2019].
    • The BASH guideline notes that serious causes of secondary headache are uncommon, and rarely present with isolated headache. Sudden-onset, severe ('thunderclap') headache, however, needs emergency hospital admission for urgent CT imaging and possible lumbar puncture to exclude subarachnoid haemorrhage [Ahmed, 2019].
  • The EHF joint publication notes that a person may have more than one type of headache concomitantly [Steiner, 2019].
Clinical features on history taking
  • The recommendations on history taking are based on the NICE guideline [NICE, 2021b], the BASH guideline [Ahmed, 2019], the EHF joint publication [Steiner, 2019], and the joint NHS RightCare publication [NHS RightCare, 2019].
    • The NICE guideline stresses the importance of making a positive diagnosis of headache (with reassurance that other pathology has been excluded) so that an appropriate explanation and management can be arranged [NICE, 2021b]. Accurate diagnosis of primary headache disorders can help to reduce chronic symptoms, medication overuse headache, and the impact on a person's daily functioning, other medical conditions, and quality of life [NHS RightCare, 2019].
    • The BASH guideline highlights that the severity of headache, clinical characteristics, and response to treatment do not help to differentiate primary from secondary headaches.
    • Cluster headache attacks can occur at the same time each day, can be seasonal, and can occur at the same time each year [Ahmed, 2019]. Medication overuse headache is present and often worse in the early morning [Steiner, 2019].
    • A recurrent episodic headache in isolation is most likely to be due to a primary headache disorder, with no associated underlying condition or disorder [Ahmed, 2019].
    • A unilateral headache is usually caused by a trigeminal autonomic cephalgia such as cluster headache, but 20–40% of people with migraine have a unilateral headache [Ahmed, 2019].
    • If a recent-onset and/or progressive headache is associated with systemic features and/or focal neurological signs, there is an increased likelihood of secondary headache precipitated by another condition or disorder which needs specialist assessment [Ahmed, 2019].
    • The NICE guideline notes that clinical features of chronic migraine and chronic tension-type headache often overlap, and if there are features of migraine, this should be the working diagnosis.
    • The BASH guideline notes that aura affects about one-third of people with migraine but is not unique to this condition, and may occur with other forms of primary headache. It also notes that cranial autonomic features are typical of a trigeminal autonomic cephalgia including cluster headache, but can also occur in people with migraine.
    • The information that tension-type headache does not typically have associated symptoms is based on the NICE guideline.
    • The NICE guideline states that menstrual-related migraine should be suspected if migraine occurs predominantly between 2 days prior and 3 days after the onset of menstruation in at least 2 out of 3 menstrual cycles.
    • Headache aggravated by postures or manoeuvres which raise intracranial pressure, or headache triggered by coughing, exercise, or sexual activity may indicate an intracranial space-occupying lesion [Steiner, 2019].
    • A history of medication prescribed or used over-the-counter can help to identify people with possible medication overuse headache [Ahmed, 2019; Steiner, 2019]. The NICE guideline emphasizes that a diagnosis of medication overuse headache should be considered in a person whose headache developed or worsened while taking ergotamine, triptan, opioid, or simple analgesia medication for 3 months or more. The NHS RightCare publication notes that reported non-response to treatment may indicate a diagnosis of medication overuse headache or chronic migraine.
Clinical features on examination
  • The recommendations on examination are based on the NICE guideline [NICE, 2021b], the BASH guideline [Ahmed, 2019], and the EHF joint publication [Steiner, 2019]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • The presence of abnormal neurological signs increases the chance of a neurological abnormality, therefore fundoscopy should be performed as part of the neurological examination [Ahmed, 2019].
    • If there are abnormal neurological signs suggesting a secondary headache disorder, specialist referral or admission for further investigation including neuroimaging is needed [Ahmed, 2019; Steiner, 2019; NICE, 2021b].
    • The information that a secondary headache is unlikely if there are no red flags on history taking and neurological examination is normal is based on the BASH guideline.
Considering arranging investigations
  • The recommendations on arranging investigations are based on the NICE guideline [NICE, 2021a], the EHF joint publication [Steiner, 2019], the EHF consensus document [Mitsikostas, 2015], and the NHS RightCare joint publication [NHS RightCare, 2019].
    • The information that there are no useful diagnostic tests for primary headache disorders is based on the EHF joint publication [Steiner, 2019] and is also extrapolated from the NHS RightCare joint publication. The NICE guideline stresses that referral for neuroimaging is not needed for reassurance alone, for people diagnosed with tension-type headache, migraine, cluster headache, or medication overuse headache.
    • The NICE guideline recommends considering use of a headache diary for at least 8 weeks to help diagnose a primary headache. This approach is supported by the NHS RightCare and EHF joint publications, with the latter noting that information on headache pattern, frequency, and response to medication can help to diagnose the headache disorder including medication overuse [Steiner, 2019].
    • The recommendation to seek specialist advice or arrange referral if the diagnosis remains uncertain is based on the EHF consensus document [Mitsikostas, 2015] and the NHS RightCare joint publication.

Supporting evidence

This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) guideline Headache in over 12s: diagnosis and management [NICE, 2021b], the British Association for the Study of Headache (BASH) guideline National headache management system for adults [Ahmed, 2019], the International Headache Society (IHS) publication The International Classification of Headache Disorders, 3rd edition [IHS, 2018], the European Headache Federation (EHF) joint publication Aids to management of headache disorders in primary care (2nd edition) [Steiner, 2019], and expert opinion in review articles. The rationale for recommendations is summarized in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care assessment of headache.

Search dates

 August 2017 - February 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Headache/, exp Headache Disorders, Secondary, exp Cluster Headache/, exp Headache Disorders, Primary/, exp Tension-Type Headache/, exp Headache Disorders/, headache.tw.
  • (Migraine OR "Migraine Disorders"/, ((tension OR cluster) AND headache)).kw,ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Ahmed, F., Bahra, A., Tyagi, A. and Weatherby, S. (2019) National headache management system for adults, 2019. British Association for the Study of Headache. http://www.bash.org.uk [Free Full-text]
  • Do, T.P., Remmers, A., Schytz, H.W., et al. (2019) Red and orange flags for secondary headaches in clinical practice. Neurology 92(3), 134-144. [Abstract]
  • IHS (2018) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 38(1), 1-211. [Abstract]
  • Latinovic, R., Gulliford, M. and Ridsdale, L. (2006) Headache and migraine in primary care: consultation, prescription, and referral rates in a large population. Journal of Neurology, Neurosurgery and Psychiatry 77(3), 385-387. [Abstract]
  • Mitsikostas DD, Ashina M, Craven A, Diener HC, Goadsby PJ, Ferrari MD, Lampl C, Paemeleire K, Pascual J, Siva A, Olesen J, Osipova V, Martelletti P; EHF committee. (2015) European Headache Federation consensus on technical investigation for primary headache disorders. Journal of Headache and Pain(15:5).
  • NHS RightCare (2019) Rightcare: headache and migraine toolkit optimising a headache and migraine system. NHS England. http://www.england.nhs.uk [Free Full-text]
  • NICE (2013) Quality standard: Headaches in over 12s. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • NICE (2021a) Suspected cancer: recognition and referral. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2021b) Headaches in over 12s: diagnosis and management. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Steiner, T.J., Stovner, L.J., Katsarava, Z., et al. (2014) The impact of headache in Europe: principal results of the Eurolight project. Journal of Headache and Pain 15(31).
  • Steiner, T.J., Jensen, R., Katsarava, Z., et al. (2019) Aids to management of headache disorders in primary care (2nd edition). Journal of Headache and Pain 20(1). [Abstract]
  • Underwood, R., Kennis, K. and Ridsdale, L. (2017) Achieving a balance between the physical and the psychological in headache. British Journal of General Practice 67(661), 374-375.
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