Persistent/recurrent headache

Persistent/recurrent headache

Reassure

  • Persistent headache on most days over a four week period
  • No worrying features
  • No associated symptoms
  • No associated high risk conditions
  • Normal neurological examination

Action

Reassure - an isolated headache, with no other symptoms and lasting for more than four weeks is unlikely to be a brain tumour.

Review/refer

  • Headache duration less than four weeks
  • No worrying features
  • No associated symptoms
  • No associated high risk conditions
  • Normal neurological examination

Action

Observe and review four weeks after headache onset, repeat history and examination. If the headache remains, but there are still no other worrying features or associated symptoms, reassure.

Scan

  • Headache with worrying features
  • Headache with abnormal neurological examination
  • Headache with associated high risk condition
  • Headache with one or more other symptoms from symptom checklist

Action

Scan

Diagnostic pitfalls

  • Delayed diagnosis has occurred when a complete reassessment is not undertaken with a change in headache type in a known sufferer of migraine or tension headaches

Examination/assessment

  • Determine duration and characteristics of headache
  • Ask specifically about associated symptoms and risk factors:
    • Personal or family history of a brain tumour
    • Leukaemia
    • Sarcoma and early onset breast or bowel cancer prior therapeutic CNS irritation
    • Neurofibromatosis types 1 and 2
    • Tuberous Sclerosis
    • Li Fraumeni Syndrome
    • Family history of colorectal polyposis
    • Gorlins Syndrome
    • Other familial genetic syndromes
  • Neurological examination (include assessment of vision (including acuity), gait and coordination)
  • Plot growth in all children
  • Plot head circumference in children under two
  • Plot pubertal status if applicable

Worrying features

  • Persistent headaches that occur on waking or wake a child from sleep
  • Headache associated with confusion/disorientation/reduced consciousness/pervasive lethargy
  • Persistent headache in a child younger than four years
  • Headache with other neurological symptoms or signs