Persistent headache - Red flag symptoms

Dr Harry Brown explains how to distinguish the rare but possibly more significant causes of persistent headache

Subdural haematoma: a possible serious cause of persistent headache
Subdural haematoma: a possible serious cause of persistent headache
Red flag symptoms
  • Early morning headache
  • New, persistent and unexplained headache in a patient aged over 50 or under 10 years
  • Associated with changes in posture or vomiting
  • Following recent head injury (within the previous 90 days)
  • Changes in personality, cognition or conscious level, or associated with new-onset seizure
  • Observed neurological deficit
  • Precipitated by coughing, sneezing or exercise
  • Associated with visual disturbance or jaw claudication (giant cell arteritis)
  • Immunosuppressed or history of malignancy

Headache is a very common presenting problem, both as an acute (not further considered here) and as a persisting problem.

The difficulty for GPs is separating the very common and non-serious from the rare but more significant, which may require urgent specialist referral or imaging.

Even within the non-serious cases, patients may be experiencing significant morbidity from migraine or tension headache.


As is often the case, a detailed history will help the busy GP to focus on a possible list of causes and a detailed clinical examination may help to delineate the problem further.

Always ask the patient what they mean by a headache, and establish the location, quality, duration, frequency, diurnal variation, precipitants, effect on activities, response to analgesics and severity.

The red flag symptoms listed above will help to guide the history. It can also be helpful to have a corroborative history from an accompanying family, friend or carer.

Always consider past medical history and medication use. A progressive history, or a history of fits, faints or blackouts should be enquired about in more detail.


General demeanour, conscious level, BP, pulse and temperature, as well as checking for papilloedema or pupil changes, can all assist in the diagnosis of persistent headache.

Assessing the patient for local neurological signs may also contribute to understanding the situation more clearly.

Always think about the possibility of giant cell arteritis, because this can be easily overlooked, with potentially devastating consequences.

When to refer

A significant cause for a headache will inevitably lead to specialist referral.

Often, an important question is how to access the services in the most efficient and quickest way.

If giant cell arteritis is suspected, the GP could request some basic bloods, start the patient on steroids and refer onwards, depending on the local protocol.

Referral points could include a same-day referral to an acute team, a two-week cancer referral or urgent referral for a specialist opinion.

If you are unclear what to do, a telephone call or email exchange with a local neurologist may also be very useful. If imaging is available with a short wait and rapid reporting, this may be an option, although it may not always provide a conclusive answer.

A progressive, severe headache that is of relatively new onset should always be taken seriously and its nature established by a detailed history and focused examination.

  • Dr Brown is a GP in Leeds
Possible serious causes of headache
  • Giant cell arteritis
  • Benign intracranial hypertension
  • Brain tumour or abscess
  • Acute glaucoma
  • Subdural haemorrhage

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