NICE summary - headache (features when it is suggested that investigation or referral is required in children 12 years or older and adults)

Last edited 05/2019 and last reviewed 10/2020

Assessment of headaches:

Summary points from NICE are(1):

Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral:

  • worsening headache with fever
  • sudden-onset headache reaching maximum intensity within 5 minutes
  • new-onset neurological deficit
  • 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 (headache that changes with posture)
  • symptoms suggestive of giant cell arteritis
  • symptoms and signs of acute narrow-angle glaucoma
  • a substantial change in the characteristics of their headache

Consider further investigations and/or referral for people who present with new-onset headache and any of the following:

  • 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

The two week referral criteria for a suspected brain tumour is linked below.

Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.

Consider using a headache diary to aid the diagnosis of primary headaches

If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:

  • frequency, duration and severity of headaches
  • any associated symptoms
  • all prescribed and over the counter medications taken to relieve headaches
  • possible precipitants
  • if female and of having periods - relationship of headaches to menstruation