If headache and ANY of the following, 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

If new-onset headache and ANY of the following, consider the need for further investigations and/or referral:

• Immunocompromised (e.g. HIV, use of immunosuppressive drugs)
• <20 y/o + history of malignancy
• History of malignancy known to metastasise to the brain
• Vomiting without other obvious causes

NICE recommends considering the use of a headache diary for at least 8 weeks to aid the diagnosis of primary headaches. The person should record the following:

• Frequency, duration and severity of headaches
• Any associated symptoms
• Possible precipitants
• Relationship of headaches to menstruation
• All medications taken to relieve headaches

 

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

NICE recommends clinical diagnosis, according to the following headache features:
 

Headache feature	Seen in cluster headache
Pain location	Unilateral (around the eye, above the eye and along the side of the head / face)
Pain quality	Variable (sharp / boring / burning / throbbing / tightening)
Pain intensity	Severe or very severe
Duration	15-180 minutes
Effect on activities	Restlessness or agitation
Other symptoms	Ipsilateral autonomic features: Red and/or watery eye Nasal congestion and/or runny nose Swollen eyelid Forehead and facial swelling Constricted pupil and/or drooping eyelid (partial Horner syndrome)

 

NICE Headaches in over 12s: diagnosis and management
NICE CKS Headache - cluster