NICE on headache (http://guidance.nice.org.uk/CG150). Guidance on assessment:
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.
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
- relationship of headaches to menstruation.
This table is taken directly from www.guidance.nice.org.uk/cg150 and helps with the classification of the specific type of headache.
| Headache feature | Tension-type headache | Migraine (with or without aura) | Cluster headache | |||
| Pain location1 | Bilateral | Unilateral or bilateral | Unilateral (around the eye, above the eye and along the side of the head/face) |
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| Pain quality | Pressing/tightening (non-pulsating) | Pulsating (throbbing or banging in young people aged 12–17 years) | Variable (can be sharp, boring, burning, throbbing or tightening) | |||
| Pain intensity | Mild or moderate | Moderate or severe | Severe or very severe | |||
| Effect on activities | Not aggravated by routine activities of daily living | Aggravated by, or causes avoidance of, routine activities of daily living | Restlessness or agitation | |||
| Other symptoms | None | Unusual sensitivity to light and/or sound or nausea and/or vomiting Aura2 Symptoms can occur with or without headache and:
Typical aura symptoms include visual symptoms such as flickering lights,
spots or lines and/or partial loss of vision; sensory symptoms such as numbness and/or pins and needles; and/or speech disturbance. |
On the same side as the headache:
|
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| Duration of headache | 30 minutes–continuous | 4–72 hours in adults 1–72 hours in young people aged 12–17 years |
15–180 minutes | |||
| Frequency of headache | < 15 days per month | ≥ 15 days per month for more than 3 months | < 15 days per month | ≥ 15 days per month for more than 3 months | 1 every other day to 8 per day3, with remission4 > 1 month |
1 every other day to 8 per day3,
with a continuous remission4 <1 month
in a
12-month period
|
| Diagnosis | Episodic
tension-type headache
|
Chronic tension-type headache5 | Episodic migraine (with or without aura) | Chronic migraine6 (with or without aura) | Episodic cluster headache | Chronic cluster headache |
| 1 Headache pain can be felt in the head, face or neck. 2 See recommendations 1.2.2, 1.2.3 and 1.2.4 for further information on diagnosis of migraine with aura. 3 The frequency of recurrent headaches during a cluster headache bout. 4 The pain-free period between cluster headache bouts. 5 Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine. 6 NICE has developed technology appraisal guidance on Botulinum toxin type A for the prevention of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine). |
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