Pre-referral guidelines for primary care providers

Headache is an extremely common childhood presentation.

For the diagnosis and management of headache, please refer to the Royal Children’s Hospital clinical practice guidelines.

Practice Points

  • It is important to distinguish more concerning headache from the common chronic causes of headache such as:
    • migraine - intermittent severe often unilateral pain +/- associated nausea & photophobia
    • tension headache - frequent, often daily, commonly late in day with few associated symptoms
  • The pattern of headaches often gives the biggest clue to the diagnosis.
  • Migraines and tension headaches generally do not require neuroimaging.
  • Neuroimaging for headaches must weigh up the significant radiation dose when using CT.
  • Red flags for headaches that warrant further investigation and/or referral include:
    • progressive
    • acute severe
    • focal neurology
    • early morning headache or vomiting
    • age < 3 years old
    • hypertension

Referral pathways

  • Paediatrician
    • Most headaches can be adequately managed in the general practice setting. For further information regarding management of migraine and tension headaches see the Kids Health Info site.
    • Referral to paediatric outpatient services can be considered in the assessment and management of headaches when red flags are present, or if other measures have failed.
      • Information to bring to any appointments:
        • headache diary, including severity
        • any investigations performed previously
        • any reports from other health professionals.
    • Sudden onset acute severe headaches or those with associated neurological change require referral to Emergency Department or consultation with paediatric services.
  • Neurologist
    • Referral to neurology services can be considered after consultation with general paediatric services.
  • Psychologist
    • Referral to mental health services is an important adjunct to medical modalities in the management of chronic headache, particularly for tension headaches.
  • Other therapies
    • Alternate therapies for chronic headaches, particularly tension headaches, include acupuncture, relaxation therapies, aromatherapy, etc.