New headache toolkit offers tips to improve management in primary care

GPs should use standardised headache assessment criteria and headache diaries to avoid unnecessary referrals to secondary care, a new NHS toolkit advises.

Accurate classification and treatment has the potential to reduce referrals for unnecessary investigations and contribute to improved quality of life for people with a primary headache disorder. | GETTY IMAGES

Developed in partnership with the Neurological Alliance, the NHS RightCare Headache and Migraine Toolkit is intended to prevent thousands of unnecessary emergency hospital admissions every year.

Most headaches referred to secondary care end up with a diagnosis of migraine and/or medication overuse headache, which is best managed in the community. The toolkit makes several recommendations to improve the management of headaches in primary care and reduce inappropriate use of A&E and outpatient neurology services. 

GPs should use standardised assessment criteria from the British Association for the Study of Headache (BASH) and NICE to diagnose primary headache disorders (migraine, tension-type headache and cluster headache), advises the toolkit.

If a primary diagnosis cannot be made initially but there is no evidence of a secondary cause, the toolkit recommends asking the patient to complete a headache diary and reviewing this after 6–8 weeks to inform diagnostic decision-making. Diary templates are available from BASH, the National Migraine Centre and The Migraine Trust.

Patients should only be referred to secondary care if their symptoms fall outside the standard classification of primary headache disorders or they have not responded to a good trial of acute and preventative therapies, and not to confirm diagnosis of a primary headache disorder. 

Interpreting symptoms

The toolkit highlights common misinterpretations of headache symptoms that can lead to inappropriate referral.

Headaches that are worse in the morning or at night, sudden onset headache, and cognitive symptoms can all signify migraine rather than a condition requiring referral.

Headache following head trauma may simply be worsening of migraine, and a change in the characteristics of headache can be due to migraine presentation evolving with age. A headache that is worse on exercise, sex or straining can indicate it is aggravated by routine physical activity rather than specifically triggered by Valsalva activities.


The toolkit encourages healthcare professionals to support patients in self-managing their condition. Asking patients to complete a trigger diary as well as an attack diary can be useful to help them understand factors that worsen their condition. Patients should also be advised on the risk and signs of medication overuse headache, especially if they are taking triptans or opioids.

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