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

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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


  1. NICE (November 2015). Headaches - Diagnosis and management of headaches in young people and adults

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