Most patients presenting to health services with headaches have primary headache (up to 95% presenting to primary care and over 50% presenting to A&E). The most common primary headache is migraine, making up the majority of these patients. Most patients with migraine can be adequately managed in primary care. Some patients, particularly those with more frequent headache may need input from secondary care.
National headache pathway
Background
The following diagram gives an overview of the primary care pathway (through to the interface with secondary care) based on presentation at General Practice.
ACRT: Active Clinical Referral Triage
Click here to open a version of this pathway in a new tab
Red flags
Most patients do not have serious secondary headache. Red flags indicate the need for urgent assessment to exclude a secondary cause. The most consistent indicators for serious secondary causes for headache are:
- Thunderclap (sudden onset) headache (consider subarachnoid haemorrhage [SAH] and its differential)
- New focal neurological deficit on examination (e.g. hemiparesis)
- Systemic features (considering GCA, infection such as meningitis or encephalitis, etc)
- New progressive headache in a patient over 50 (most headaches presenting in patients over 50 are benign, but there is an increased risk of secondary pathology with increasing age)
Headache suggesting the possibility of a brain tumour
- New headache plus sub-acute progressive focal neurology
- New headache plus seizures
- New headache with personality or cognitive change not suggestive of dementia, with no psychiatric history and confirmed by witness
Amber flags
Features that may indicate a secondary cause but may also be seen in primary headaches:
- Changes in headache intensity with changes of posture (upright consider low pressure / headache when lying flat consider high pressure)
- Worsening/Triggering headache with Valsalva (e.g. coughing, straining)
- Atypical aura (duration >1 hour or including motor weakness)
- Progressive headache (worsening over weeks or longer)
- Head trauma within the last month
- Previous history of cancer or HIV
- Re-attendance to A&E or GP surgery with progressively worsening headache severity or frequency
Consider a secondary cause if any of these are present.
Features that do not help to differentiate primary from secondary headaches are:
- Severity
- Treatment response
Features that are supportive of a diagnosis of primary headache:
- Recurrent episodic headache, particularly with features of migraine
- Long history of daily headache
If there are no concerning features then it is appropriate to manage these patients for migraine. Other features that are pointers to migraine include a previous migraine history and a family history of migraine.
A standard examination in a patient with headache should include blood pressure, fundoscopy and a brief neurological examination looking for new focal neurological deficit.
Migraine is the commonest primary headache presenting to both primary and secondary care. It is however important to consider other primary headache disorders as per the following table.
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| Headache feature | Migraine (with or without aura) | Cluster headache | Tension-type headache |
| Frequency | Majority of patients presenting to both primary and secondary care (94% of people presenting in primary care with episodic headache will have migraine) | Rare - 1 in 1,000 | Very common, but not often seen in primary or secondary care as usually mild and self-managed |
| Duration of headache |
4 – 72 hours in adults 1 – 72 hours in young people |
15 minutes to 3 hours | 30 minutes – continuous |
| Pain location |
Unilateral or bilateral (head, face or neck) |
Unilateral (around the eye, above the eye and along the side of the head/face) |
Bilateral (head, face or neck) |
| Pain quality |
Pulsating (throbbing or banging in young people) |
Variable (can be sharp, boring, burning, throbbing or tightening) |
Pressing/tightening (non-pulsating) |
| Pain intensity | Moderate or severe | Severe or very severe | Mild or moderate |
| Effect of activities |
Aggravated by, or causes avoidance of, routine activities of daily living (e.g. prefer to stay still or go to bed) |
Restlessness or agitation | Not aggravated by routine activities of daily living |
| Other symptoms |
|
Cranial autonomic symptoms on the same side as the headache:
Patients with cluster can get migrainous symptoms and aura |
None |
Migraine is differentiated into episodic and chronic migraine.
Patients with episodic migraine have headache on 14 or less days per month (high frequency episodic migraine 10-14 days per month).
Patients with chronic migraine have 15 or more days of headache per month 8 of which should meet criteria for migraine. Chronic migraine therefore usually presents with a mixture of milder background headache and migraine.
- Patients with migraines often underplay their symptoms
- Recurrent ‘sinus headache’ and/or dizziness is usually migraine
- In patients with chronic migraine, there is usually background headache with superimposed migraine days
- In patients taking acute treatment on 10 days/month, consider medication overuse headache
- Most patients waking with headache have migraine or medication overuse headache (withdrawal of overused analgesia overnight)
- Menstrual headache is almost always migraine and migraine usually improves in pregnancy
- Most patients with migraine are sensitive to head movement during a migraine so bending, coughing or sneezing during a migraine may make headache worse (motion sensitivity)
- Most patients with migraine don't have aura
- 40% of migraine is bilateral
Migraine is the most likely diagnosis for a patient attending primary care with headache. Many of these patients will be successfully managed in primary care. If there is a clear diagnosis of migraine we recommend acute +/- preventative treatment (as detailed in the acute and preventative treatment sections).
Where preventative treatment is not successful after a trial of three preventative medications at an adequate dose and for an adequate length of time, consider referral to relevant secondary care services as per local arrangements.
If there is diagnostic uncertainty or concern about a secondary cause, consider open access CT as an alternative to secondary care referral.
Patients should be directed to the resources available on NHS Inform for lifestyle advice. Where consultation time allows the following key points should be made in relation to lifestyle.
Regular sleep pattern.
Regular eating pattern / don’t skip meals (more frequent small meals may help).
Regular fluid intake but limit alcohol, and limit caffeine from tea, coffee and some soft drinks.
Regular physical activity/exercise
Regular breaks from computers/phone screens
Relaxation activities such as mindfulness, yoga or meditation
Manage potential triggers as needed; e.g. avoid perfumes, certain food triggers if applicable, bright, flashing or flickering lights (consider wearing sunglasses when outside or in bright, flashing or flickering light)
Further advice is available from the Migraine Trust on 0808 802 0066 or https://migrainetrust.org/what-we-do/our-information-and-support-service/
SIGN 155 Clinician Guidance SIGN 155 Pharmacological management of migraine (revised May 2026)
SIGN 155 patient guidance SIGN Migraine patient booklet PAT155 (revised May 2026)
Migraine Trust: Home - The Migraine Trust
Heads up podcasts from the National Migraine Centre Heads Up podcast - National Migraine Centre
British Association for the Study of Headache (BASH) National Management System 2019
Mollan S. et al. Evaluation and Management of adult idiopathic intracranial hypertension. Practical Neurology. 2018. Evaluation and management of adult idiopathic intracranial hypertension (bmj.com)
Cheema S. et al. Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension. JNNP. 2023. https://jnnp.bmj.com/content/early/2023/05/04/jnnp-2023-331166
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