HNY Policy and Pathway Repository - Humber

A headache management education programme aimed at assisting GP’s in the management of patients aged over 12 with primary headache disorders. The programme will be led and delivered by the Headache Specialist Nurse.

Headache disorders are classified as primary or secondary. Primary headaches are classified according to their clinical pattern. 

Secondary headaches are attributed to underlying disorders and include headaches associated with medication overuse, giant cell arteritis, raised intracranial pressure and infection.  Medication overuse headache most commonly occurs in those taking medication for a primary headache disorder. 

The programme will provide GP’s with an alternative to secondary care referral via the 18-week pathway.

Referrals will be accepted for:

• Migraine
• Cluster Headache
• Tension Headache
• Medication overuse headache
• Undiagnosed Chronic Headaches (No Red Flags)

1. New onset of headaches (< 3 months) or change in the characteristics of existing migraineurs

in patients with:

1. 1. Recent diagnosis of cancer elsewhere e.g. breast, prostate, lungs, bowel etc.
   2. Immunosuppressed e.g. steroids or other immunomodulators.
   3. Patients aged 60 or more
   4. Patients with raised inflammatory markers that cannot be explained.
2. Patients with abnormal neurological examination e.g. papilloedema, altered mentation.
3. Patients whose typical migraine aura lasts for longer than an hour.
4. Patients with persistent aura.
5. Patients with thunderclap headaches i.e. hyperacute onset that peaks in less than 5 minutes.
6. Patients with valsalva headaches:
   1. Definite relationship with change in posture
   2. Only precipitated with coughing, sneezing, straining, and bending forward.

The programme will be delivered as a weekly group session and led by the Headache Specialist Nurse. The Sessions will cover:

• Overview of common primary headaches
• When to worry / when to see your GP
• Overview of available treatments
• Diet and lifestyle
• Relaxation exercises
• Medication overuse and detoxification
• Assessment tools and headache diaries
• Complete Headache Questionnaire HIT-6
• Summarise headache diary
• Patient role in own care and headache management
• Information healthcare professionals require to make a diagnosis
• Managing expectations of healthcare and treatments

Patient returns to GP Surgery after 6 weeks where the Headache diagnosis can then be confirmed and GP can implement management plan as per NICE guidance on Headaches.

If Medication overuse identified, plan detoxification then re-assesses with further headache diaries 6 weeks post detoxification.

If a primary headache diagnosis is made manage as per NICE guidelines. 

If Chronic Migraine is identified and patient fulfils NICE criteria for treatment with Botox consider referral straight to Chronic Migraine Service offering Botox,  Align referral with Humber and North Yorkshire Policy -Botulinum toxin A for chronic migraine - Hull - HNY Policy and Pathway Repository

If diagnosis remains unclear GP should consider referral to Headache Service, Hull University Teaching Hospitals NHS Trust and ask patient to continue to maintain headache diaries.  Diaries are available on the British Association for the Study of Headache website https://bash.org.uk/guidelines/

Do Not Refer

NICE clinical guideline 150 lists the signs and symptoms of secondary headaches for which further investigations and/or referral to Neurology / Headache Specialist may be considered:

• Worsening headache with fever
• Sudden-onset headache reaching maximum intensity within 5 minutes
• New-onset neurological defect
• New-onset cognitive dysfunction
• Change in personality
• Impaired level of consciousness
• Recent (typically within the past 3 months) head trauma
• Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
• Headache triggered by exercise
• Orthostatic headache (headaches that change with posture)
• Symptoms suggestive of giant cell arteritis
• Symptoms and signs of acute narrow-angle glaucoma
• A substantial change in characteristics of their headache.

NICE clinical guideline 150 also states criteria for which further investigations and/or referral may be considered for people who present with new-onset headache. These are:

• Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
• Age under 20 years and a history of malignancy
• A history of malignancy known to metastasise to the brain
• Vomiting without other obvious cause (for example a migraine attack).

Referral Criteria

Out-Patient Referrals Guidelines (For those over the age of 116)

1. Chronic Daily Headaches i.e., occurring on more than 15 days a month for more than three months are welcomed to be referred in the headache clinic provided:

1. Those overusing painkillers (prescribed or over the counter) be advised to reduce or preferably stop the painkillers prior to clinic visit.
2. Advising the patient to maintain a headache diary before clinic visit (Using Hull Headache Diary).
3. Clearly detail on the prophylactic drugs they have tried including name, doses and duration of each drug.

2. Episodic Headaches i.e. occurring on 14 or less days in a month for more than three months with or without features of migraine (Nausea, Vomiting, Sensitivity to light sound or smell and motion sensitivity) should only be referred if:

1. If you have a doubt on the diagnosis (state why)
2. If you think they have one of the red flags
3. If they have been refractory to at least three preventive drugs used at an appropriate dose for at least three months. These include

1. Tricyclic antidepressants (Amitriptyline 30 mg max)
2. Beta blockers (Propranolol 160 mg max)
3. Candesartan (8mg BD max). Effective contraceptive advice should be given to women on candesartan.
4. Anti-convulsant (Topiramate 100 mg max) (In Male patients, avoid in Female patients due to teratogenicity as per MHRA guidance.)

3. New Daily Persistent Headaches i.e., a daily headache of less than three months with or without red flags with no previous history or a change in the characteristic of headache in previous sufferers.
4. Patients with headaches lasting less than 4 hours (without treatment) that are suspected of having rare headache syndromes such as cluster headaches. Please ensure:
   1. These headaches are excruciating, strictly unilateral and side locked with autonomic features such as lacrimation, conjunctival injection, rhinorrhoea in the first division of the trigeminal nerve. (Likely cluster)
   2. Sharp Stabbing electric shock like pains in the second or third division of trigeminal nerve (likely trigeminal neuralgia)

Please use NHS electronic Referral Service (eRS) to Headache Disorders at Hull University Teaching Hospitals NHS Trust (RWA) adding all patient details, history and medications. 

British Association for the Study of Headaches (BASH) Guidelines - https://bash.org.uk/guidelines/  

Scottish Intercollegiate Guidelines Network (SIGN) (2008) Diagnosis and management of headache in adults (107) - https://www.orofacialpain.org.uk/downloads/Headaches/sign107%20headache.pdf

HNY Policy - Botulinum toxin A for chronic migraine - Hull - HNY Policy and Pathway Repository

NICE guidelines for Primary Headache Diagnosis (CG150 – 2012 – Updated 2025)

NICE criteria for treatment with Botox (TA260 – June 2012)

Directory of Service for Headache Disorders

• Hull University Teaching Hospitals