Draft for consultation only
Referral to emergency
If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.
- headache with concerning features:
- sudden onset severe thunderclap headache
- sudden onset or severe headache triggered by cough, exertion or sexual activity
- severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
- associated abnormal neurological examination and/or altered or impaired consciousness
- first severe headache age ≥ 50 years
- severe headache associated with recent head trauma
- age ≥ 50 years with raised C-reactive protein/erythrocyte sedimentation rate (ESR) or giant cell arteritis or vasculitis suspected
- a worsening or different headache with other red flag features should be considered as an emergency, even in the setting of known chronic headache disorder
- in the case of suspected raised intracranial pressure but without any of the above features
- arrange urgent ophthalmological examination to look for papilledema
- arrange urgent cerebral imaging to exclude space occupying lesion or cerebral venous sinus thrombosis
- features of raised intracranial pressure may include:
- headache worse in the morning
- headache exacerbated by coughing, sneezing, straining or bending forwards
- pulsatile tinnitus
- visual symptoms – including transient reduction in vision with straining
- if features of raised intracranial pressure and abnormal cerebral imaging
- if features of raised intracranial pressure and normal cerebral imaging and normal neurological examination, urgent referral to neurology clinic (see ‘exclusions and triage categories – category 1’)
For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.
Central Adelaide Local Health Network
- Royal Adelaide Hospital (08) 7074 0000
- The Queen Elizabeth Hospital (08) 8222 6000
Northern Adelaide Local Health Network
- Lyell McEwin Hospital (08) 8182 9000
- Modbury Hospital (08) 8161 2000
Southern Adelaide Local Health Network
- Flinders Medical Centre (08) 8204 5511
- migraine headaches which have not been previously treated in a primary care setting, including trials of at least two migraine prevention medications
- radiological features of intracranial hypertension without clinical features
- it is strongly recommended that any analgesic (especially opioids including codeine) or triptan overuse (that is > 10 days per month) is addressed whilst awaiting review
Category 1 — appointment clinically indicated within 30 days
- clinically suspected intracranial hypertension i.e. headache with papilledema and without venous sinus thrombosis or intracranial mass
- uncontrolled/disabling trigeminal neuralgia despite trials of at least two first line medications
- uncontrolled trigeminal autonomic cephalgia despite trial of verapamil (i.e. cluster headache)
Category 2 — appointment clinically indicated within 90 days
- disabling migraine headaches despite trials of at least two first line migraine preventive medications
- a third prophylactic agent and headache diary should be commenced while awaiting review
- cluster headache/trigeminal autonomic cephalgia in remission but needing ongoing assessment or management
Category 3 — appointment clinically indicated within 365 days
- headaches not meeting above criteria where specialist input is required for diagnosis or management
For information on referral forms and how to import them, please view general referral information.
Essential referral information
Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
- complete past medical history
- current medication list including non-prescription medication, herbs and supplements
- alcohol and other drugs history
- list all treatments trialled (including maximum dose reached and duration of therapy) for migraines or other episodic disabling headaches
- clinical history including:
- onset and duration of headaches
- frequency of headaches
- pain description (location, quality)
- associated functional impairment
- associated features e.g. autonomic features, vomiting, photophobia
- screening neurological examination
Additional information to assist triage categorisation
- complete blood examination (CBE)
- electrolytes, urea, creatinine (EUC)
- liver function tests (LFTs)
- C-reactive protein (CRP)
- erythrocyte sedimentation rate (ESR)
In cases of suspected intracranial hypertension this should be performed prior to referral to exclude emergency cause of headache. Magnetic resonance imaging (MRI)/magnetic resonance venography brain is preferred but may not be accessible in some cases, in which a computed tomography (CT) brain with venogram should be considered.
Please provide details of neuroimaging done including radiology provider and accession number.
Clinical management advice
Not all referrals require consultation with a neurologist and patients may be reviewed in advanced practice nurse led clinics where medically appropriate. Nurse led clinics are part of best evidence-based practice and have been shown to reduce patient wait times, increase consultation duration, increase patient engagement and satisfaction; improve communication and provide access to tailored advice on self-management of disease and illness.
Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.
If the patient you are referring requires urgent attention and/or fulfils category 1 triage criteria, it is strongly recommended that you contact the outpatient department to ensure your referral has been received.
- HealthPathways SA - Headaches in Adults (log in required)
- Australian and New Zealand Headache Society (ANZHS) - Clinician Resources
- Adelaide Primary Health Network - Resource Library (Headache and Facial Pain Therapeutic Guidelines)