QUEEN MARY’S HOSPITAL
Radiology Dept.
Patient details
Roehampton Lane
SW15 5PN
Tel: 0208 487 6512/6513
Male/Female
Surname:
GP Details
First name:
Surgery
DOB:
GP
Address:
Fax No:
Phone No:
Pathway for CT head Referral in Adult (Over 18) Patients with Chronic Persistent
Headache
PhonenO:
Is there any abnormal neurology on
examination
Patient consults with headache
After clinical examination and
medical history are there any
red flag features
TREAT AS PRIMARY
HEADACHE DISORDER
No
Yes
Red Flag features
Yes
If routine Rx does not lead to anticipated
improvement
OR Unusual features
OR MigraIne criteria not met
No
New onset of headache in patient >50
Increasing frequency + severity of headache
Headache that bothers/wakens patient
REFER
FOR CT
HEAD
History of malignant disease/HIV
If yes
Focal neurological signs
Signs of disease
Palpitations
Additional essential information
PLEASE NOTE
Walk in Service 9 am to 4 pm Monday to Friday
Patient to bring Request Form to Radiology Dept.
Possiblity of Pregnancy :
YES
1.
2.
3.
4.
5.
6.
How long has headache been present?
?PHx head/brain surgery
?PHX head injury
?PHx fit/collapse
?PHx epilepsy
?PHx any malignancy
NO
LAS LMP
GP Signature
Patient Signature
Date
If yes
to any
No