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
Refer for an MRI 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
• Ask specifically about associated symptoms and risk factors:
• Neurological examination (include assessment of vision (including acuity), gait and coordination
• Plot growth in all children and pubertal status if applicable
• 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
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