Headache Red Flags for Primary Care

Headaches That Require Specialist Assessment

“These include any primary headache that is not getting better or getting worse despite treatment. If I have a patient with any neurologic abnormalities, I will refer to a neurologist. Patients who work in front of a computer all day and have headaches may be referred to a neurologist. Patients who are on narcotics or who are looking for narcotics may get referred to pain management,” says Dr Boling.

“Watch out for hemorrhage headaches in patients on anticoagulants. Watch out for patients with AIDS, cancer, or immunosuppression. Headaches in these patients may signal an opportunistic space-occupying lesion. Watch out for a first headache soon after pregnancy. This is a period of hypercoagulability that could cause thrombosis,” warns Dr Newman.

Other headaches that warrant referral include the following:

  • A new headache in a patient age 50 years or older, especially with jaw or visual symptoms could be indicative of temporal (giant cell) arteritis.1 “This headache is more common in women. Sedimentation rate is a good diagnostic test to order,” says Dr Boling. This referral should be considered urgent because sudden blindness is a potential dangerous complication.1,2
  • An elderly patient with a new headache and cognitive decline may have a subacute or chronic subdural hematoma. This can occur in the absence of a history of trauma.1
  • Consider referral for a migraine that does not respond to treatment. “Intractable migraine or migraine that has not responded to ‘my bag of tricks’ is referred to the neurologist,” says Dr Boling.
  • Chronic tension headache is a headache that may be best managed in a pain management clinic.2

“Cluster headache should be managed by a neurologist. This is a frequently missed diagnosis. This headache is difficult to manage. A patient often has seen [as many as] 5 different clinicians before receiving the right diagnosis and treatment, “says Dr Newman.

Another headache that is increasingly common and could benefit from a pain management referral is that caused by medication overuse. Patients may start by using an over-the-counter headache medication too frequently and progress to using daily medication prophylactically. 1,2 “Overuse headaches are common with nonsteroidal anti-inflammatory drugs [NSAIDs] and with medications containing caffeine. One of the most common prescription pain medications to cause this type of headache is butalbital,” says Dr Newman.


“I can treat headache in most of my patients without referring them out. It just takes a good history and a normal neurologic examination. But headaches seem to exist on a continuum. Headaches have a way of progressing, so when they are hard to manage, a referral is a good idea,” says Dr Boling.

Dr Newman agrees. “I wish we would see more headaches earlier. The longer you wait, the harder they are to treat. Episodic migraines become chronic migraines. Early treatment can prevent medication overuse. That being said, primary care can do a good job with most headaches. There are many primary care physicians and only about 500 of headache specialists. We can’t manage all the headaches, and we don’t have to,” says Dr Newman.


1. Agency for Healthcare Research and Quality, Guideline for primary care management of headache in adults. October 9, 2013. Available at: https://www.guideline.gov/content.aspx?id=47060.  Accessed May 3, 2016.

2. Clinch CR. Evaluation of acute headaches in adults. Am Fam Physician. 2001;63(4):685-693.