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Clinical guidelines

Clinical guidance for MRI referral

Bookmarks for headaches

Table 2.4 Clinical patterns of primary headaches

Headache featureTension-type headacheMigraine (with or without aura)Cluster headache
Pain locationa Bilateral Unilateral or bilateral Unilateral (around the eye, above the eye and along the side of the head/face)
Pain quality Pressing/tightening
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
Aura symptoms can occur with or without headache and:
  • are fully reversible
  • develop over at least 5 minutes
  • last 5–60 minutes.
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:
  • red and/or watery eye
  • nasal congestion and/or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil and/or drooping eyelid.
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 dayb, with remissiond > 1 month

1 every other day to 8 per dayc, with a continuous remissiond < 1 month in a 12 month period

Diagnosis Episodic tension-type headache Chronic tension type headachee Episodic migraine (with or without the aura) Chronic migrainef (with or without aura) Episodic cluster headache

Chronic cluster headache

a Headache pain can be felt in the head, face or neck.
b See recommendations 1.2.2, 1.2.3 and 1.2.4 for further information of migraine with aura.
c The frequency of recurrent headaches during a cluster bout.
d The pain-free period between cluster headache bouts.
e Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.
f 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).

Reproduced with permission from National Institute for Health and Care Excellence (NICE) from Diagnosis of tension-type, migraine and cluster headache, from Headaches: diagnosis and management of headaches in young people and adults. National Clinical Guideline Centre. p 44.

Table 2.5 Intracranial tumours

Intracranial tumours
Intracranial tumours only present as headache in 3–4% of cases. Typically they do not cause headache until they are quite large, although pituitary tumours are an exception.24
The incidence of headache with brain tumour is the same as the incidence of headache in the general population.15
Brain tumours are more common in males and with increasing age. Most malignant tumours are fatal, but approximately 30% are benign (e.g. meningioma) and grow slowly.15
Raised intracranial pressure is apparent in the history and epilepsy is a cardinal symptom of intracerebral space-occupying lesions. Loss of consciousness should be viewed very seriously.24
Most patients with brain tumour present with seizures or focal neurological signs rather than headache.24,66

Table 2.6 Giant cell arteritis

Giant cell arteritis
Giant cell arteritis (GCA) is the result of inflammation of the cranial arteries, especially branches of the external carotid artery.67
The variability in symptoms is such that any recent persisting headache in a patient over 60 years of age should raise the suspicion of GCA. Headache is the best known symptom but it is very variable and not always present. When present, it is likely to be persistent, worse at night and it can be severe. It is localised to the temple(s) in only a minority of cases.24
Patients with GCA may be systemically unwell. Jaw claudication may be absent, but when it is present, it is highly suggestive of GCA.67 Most but not all patients have temporal artery tenderness and/or diminished pulsation.
Because of the risk of blindness due to anterior ischaemic optic neuropathy, high-dose oral steroids should commence urgently and before waiting for temporal artery biopsy.
MRI does not detect GCA.

Table 2.7 The SNOOP-4 mnemonic

The SNOOP-4 mnemonic28
Systemic symptoms (fever, weight loss) or secondary risk factors (HIV, cancer)
Neurological symptoms or abnormal signs (confusion, impaired alertness or consciousness)
Onset – sudden, abrupt or split second (‘thunderclap’)
Older – new onset or progressive headache, especially in patients older than 50 years (giant cell arteritis)
Previous headache history – first headache or different headache (change in attack frequency, severity or clinical features)
Postural or positional aggravation
Precipitated by a Valsalva manoeuvre or exertion


  1. Hamilton W, Kernick D. Clinical features of primary brain tumours: a case–control study using electronic primary care records. Br J Gen Pract 2007;57(542):695–9.
  2. Steiner TJ, MacGregor EA, Davies PTG. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. British Association for the Study of Headache 2007;2007:1–52.
  3. Zagami AS, Goddard SL. Recurrent headaches with visual disturbance. Med J Aust 2012;196(3):178–83.
  4. Grant R. Overview: brain tumour diagnosis and management/Royal College of Physicians guidelines. J Neurol Neurosurg Psychiatry 2004;75(Suppl 2):ii18–23.
  5. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33(9):629–808.
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