Leeds CCGs Targeted Interventions Referral Form
Headache Referral – Neurology Service
Referral to:
(insert patient’s choice of hospital)
Patient Details:
Title
Surname
Forename(s)
Address
Referrer Details:
Referring GP
Practice Address
Diagnostic guide: (see overleaf for details)
Episodic tension type headache
Chronic tension type headache
Migraine
Analgesic overuse headache
Cluster headache
Suspicious headache
(see also 2 week referral guidance)
More likely to need
referral to specialist

More likely to be
managed in primary
care

D.O.B
NHS Number
Tel (home)
Tel (mobile)
Gender
Ethnicity
Age
Is an interpreter required
Yes
No
Is transport required
Yes
No
Telephone
Fax
Practice Code
Please select all that apply:
Episodic tension type headache
Chronic tension type headache
Migraine
Analgesic overuse headache
Cluster headache
Suspicious headache (see also 2 week referral guidance)
Describe details of headache (duration, site, nature) Include your reasons for wanting a consultant opinion:
Describe any accompanying symptoms (visual disturbance, nausea, aura, focal neurological signs)
Describe any related or possible causative factors (stress, posture, TMJ dysfunction, sinus problem)
Please provide details of previous treatment regimens including doses and durations:
Significant past medical history:
Review Date: April 2016
Current medication:
GP Signature:
Date:
Headache Symptoms - A symptom based guide to possible diagnosis:
(note: more than one type of headache may co-exist)
Episodic tension type headache:
(affects 80% of the population)
Typically bilateral, often band-like or pressure feeling, may have muscle tenderness, may be stress
related.
(may respond to paracetamol or NSAID)
Chronic tension-type headache:
(affects 3% of the population)
Occurs >15 days a month, may be unremitting and not respond to analgesia. May be related to stress
or long standing neck problems
(May respond to amitriptyline)
Migraine:
(affects 10% of the population)
Often unilateral, often throbbing, last up to a few days, may be aura, nausea or visual disturbance, or
focal neurology such as paraesthesia of hand, arm or face for up to 60 minutes
(If this last longer, always refer)
Analgesic overuse headache:
(affects 5% of the population)
Typically daily, oppressive, worse on walking, worse on exertion. Consider if using over 3 tablets a
day for over 3 days a week regularly.
(Ask patient to keep a headache diary)
Cluster headache:
(affects <1% of the population)
Strictly unilateral, severe/unbearable, around eye, often at night, may have red or watering eye,
rhinitis, or blocked nose. Alcohol triggers.
(Refer early to specialist)
Suspicious headache:
(affects <1% of the population)
New onset, qualitatively different, unusually severe and not responding to usual measures.
Persisting neurological signs
Optic disc changes
Suspicion of malignancy (see 2 week referral guidance)
Meningism, acute neck stiffness
Primary closed angle glaucoma
Temporal arteritis or raised ESR without cause
Suspected carbon monoxide poisoning
(Refer Urgently if any of the above are present)
Supporting evidence
Headache (BMJ 2002; 325:881-886)
www.bash.org.uk (The British Association for the Study of Headache)
www.prodigy.nhs.uk (several guidelines on managing headaches and migraine)
Review Date: April 2016