Sunday, August 5, 2012

Guidelines for Evaluation of Unusual Headache

Guidelines for primary care investigation and referral in suspected brain and central nervous system cancer.

For purposes of these guidelines, urgent referral means a follow up appointment with a specialist within two weeks.


As I have written about in the past, the US Department of Health & Human Services has a wonderful website at www.guideline.gov, that serves as a public resource for evidence-based clinical medical practice guidelines, i.e. the standard expected of physicians in various aspects of medicine.  The more Pennsylvania residents know about their health care the better care they will receive, or so I like to think.  These standards are also important for personal injury lawyers to know in order to establish whether a particular scenario is or is not malpractice.


Headaches are a typically benign condition that we all have to endure from time to time.  The majority of time, headaches are nothing to worry about.  But occasionally a headache is a symptom of a more significant condition.  When a patient presents to a doctor with headache, the doctor is responsible for considering all possible causes of the problem.  The following guidelines govern how primary care practitioners must respond to a patient presenting with headache.

A person presenting with symptoms related to the CNS (including progressive neurological deficit, new onset seizures, headaches, mental changes, cranial nerve palsy, unilateral sensorineural deafness) where a brain tumour is suspected, should be referred urgently to a specialist.

A person presenting with headaches of recent onset accompanied by either features suggestive of raised intracranial pressure (e.g., vomiting, drowsiness, postural related headache, headache with pulse synchronous tinnitus) or other focal or non-focal neurological symptoms (e.g., blackout, change in personality or memory) should be referred urgently to a specialist.

A person presenting with a new, qualitatively-different unexplained headache that becomes progressively severe, should be referred urgently to a specialist.

A person presenting with suspected recent onset seizures, as determined by the clinical history, should be referred urgently to a specialist. An imaging investigation with a computed tomography (CT) or magnetic resonance imaging (MRI) scan may be considered where available, but this should not delay referral.

A person developing new signs related to the CNS should be considered for referral to a specialist.

A practitioner with concerns about the interpretation of a person's symptoms and/or signs should consider discussion of these concerns with a specialist. Referral for MRI or CT scanning should also be considered.

A practitioner should consider discussion with a specialist when a person presents with unexplained headaches of recent onset, present for at least 1 month without features suggestive of raised intracranial pressure.  A practitioner should reassess and re-examine a person with signs and symptoms that may be related to the CNS where there is failure to improve as expected.

Friends and family of individuals suffering from headaches are advised to consider the above practice recommendations and make sure they are being following during evaluation and treatment.

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