Where to refer a patient with a headache?

When to Refer a Patient with Headache

Refer patients with headache to a neurologist when they present with cluster headache, uncertain diagnosis, poor response to preventive strategies, migraine with persistent aura, or headache with motor weakness. 1, 2

Indications for Specialist Referral

Definite Neurologist Referral Required

• Cluster headaches require specialist management due to their complex treatment requirements 1, 2
• Headache with motor weakness (hemiplegic migraine) necessitates neurological evaluation to exclude serious secondary causes 1, 2
• Migraine with persistent aura should be referred as this may indicate complications or alternative diagnoses 1, 2
• Uncertain diagnosis after thorough primary care evaluation warrants specialist input 1, 2
• Poor response to preventive strategies after adequate trials of evidence-based therapies indicates need for specialist care 1, 2

Chronic Migraine Requiring Specialist Input

• Chronic migraine (≥15 headache days per month for >3 months with migraine features on ≥8 days) should be referred for specialist management 3, 1
• These patients may benefit from specialized treatments including onabotulinumtoxinA or CGRP monoclonal antibodies that typically require specialist initiation 4, 1

Emergency Department Referral Indications

Immediate Referral Required for Red Flags

• "Thunderclap" headache (sudden onset, peaking within 1 second to 1 minute) requires immediate emergency evaluation for subarachnoid hemorrhage 4, 5
• New headache after age 50 needs urgent assessment to exclude temporal arteritis, mass lesions, or other serious pathology 4, 1
• Headache worsened by Valsalva maneuver (coughing, straining, bending) suggests increased intracranial pressure 4, 1
• Headache awakening patient from sleep may indicate increased intracranial pressure or serious secondary cause 4, 1
• Progressively worsening headache over days to weeks suggests evolving pathology 4, 1
• Fever or signs of infection with headache requires urgent evaluation for meningitis or encephalitis 1
• Abnormal neurological examination findings mandate immediate imaging and specialist evaluation 4, 1

Specific Red Flag Features from History

• Occipital location with sudden onset is more common in subarachnoid hemorrhage (55% vs 22% in benign headaches) 5
• "Stabbing" quality headache with sudden onset suggests SAH (35% vs 5% in benign headaches) 5
• Associated meningismus (neck stiffness) strongly suggests serious pathology (80% in SAH vs 42% in benign headaches) 5

Primary Care Management Without Referral

When Referral is NOT Needed

• Typical migraine or tension-type headache with normal neurological examination and no red flags can be managed in primary care 3, 4
• Episodic migraine responding to acute treatment with NSAIDs or triptans requires only primary care follow-up 3, 4
• Long history of similar headaches without change in pattern and normal examination does not require neuroimaging or referral 1

Primary Care Management Strategy

• Maintain patients with stable, well-controlled headaches in primary care with regular monitoring 3
• Repatriate patients from specialist care once diagnosis is established and effective treatment plan is in place 3
• React promptly to any change in headache pattern that may warrant re-referral 3

Common Pitfalls to Avoid

• Do not dismiss headache in patients over 50 as "just migraine" without thorough evaluation for secondary causes 4, 1
• Recognize medication overuse headache in patients taking analgesics >10 days per month; these patients may need specialist referral for detoxification 4, 1
• Do not delay referral for suspected subarachnoid hemorrhage even if headache has improved—65% of SAH patients report headache peaking within 1 second 5
• Avoid assuming all unilateral headaches are migraine—cluster headache requires specialist management 1, 2