headache (adult, criteria for urgent referral)

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The updated NICE urgent referral guidance for suspected brain tumour (1) is much less specific than the previous guidance (2).

The current guidance states (1):

Brain and central nervous system cancers

  • adults
    • consider an urgent direct access MRI scan of the brain (or CT scan if MRI is contraindicated) (to be performed within 2 weeks) to assess for brain or central nervous system cancer in adults with progressive, sub-acute loss of central neurological function

  • children and young people
    • consider a very urgent referral (for an appointment within 48 hours) for suspected brain or central nervous system cancer in children and young people with newly abnormal cerebellar or other central neurological function

Previous guidance (2) listed below was much more specific about different symptoms and when to refer:

Refer urgently patients with:

  • symptoms related to the CNS in whom a brain tumour is suspected, including:
    • progressive neurological deficit
    • new-onset seizures
    • headaches
    • mental changes
    • cranial nerve palsy
    • unilateral sensorineural deafness
  • headaches of recent onset accompanied by features suggestive of raised intracranial pressure, for example:
    • vomiting
    • drowsiness
    • posture-related headache
    • pulse-synchronous tinnitus
    • or by other focal or non-focal neurological symptoms, for example blackout, change in personality or memory
  • a new, qualitatively different, unexplained headache that becomes progressively severe
  • suspected recent-onset seizures (refer to neurologist)

Refer urgently patients previously diagnosed with any cancer who develop any of the following symptoms:

  • recent-onset seizure
  • progressive neurological deficit
  • persistent headaches
  • new mental or cognitive changes
  • new neurological signs.

Consider urgent referral (to an appropriate specialist) in patients with rapid progression of:

  • subacute focal neurological deficit
  • unexplained cognitive impairment, behavioural disturbance or slowness, or a combination of these
  • personality changes confirmed by a witness and for which there is no reasonable explanation even in the absence of the other symptoms and signs of a brain tumour

Consider non-urgent referral or discussion with specialist for:

  • unexplained headaches of recent onset:
    • present for at least 1 month
    • not accompanied by features suggestive of raised intracranial pressure.