Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • headache with concerning features:
    • sudden onset severe thunderclap headache
    • sudden onset or severe headache triggered by cough, exertion or sexual activity
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • associated abnormal neurological examination and/or altered or impaired consciousness
    • first severe headache age ≥ 50 years
    • severe headache associated with recent head trauma
    • age ≥ 50 years with raised C-reactive protein/erythrocyte sedimentation rate or giant cell arteritis or vasculitis suspected
    • a worsening or different headache with other red flag features should be considered as an emergency, even in the setting of known chronic headache disorder

  • in the case of suspected raised intracranial pressure without any of the above features — see clinical management advice

  • features of raised intracranial pressure and abnormal cerebral imaging

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Exclusions

  • migraine headaches which have not been previously treated in a primary care setting, including trials of at least two migraine prevention medications
  • radiological features of intracranial hypertension without clinical features
  • it is strongly recommended that any analgesic, especially opioids including codeine, or triptan overuse that is > 10 days per month, is addressed whilst awaiting review

Triage categories

Category 1 — appointment clinically indicated within 30 days

  • clinically suspected intracranial hypertension for example, headache with papilledema and without venous sinus thrombosis or intracranial mass
  • uncontrolled/disabling trigeminal neuralgia despite trials of at least two first line medications
  • uncontrolled trigeminal autonomic cephalgia despite trial of verapamil for example, cluster headache

Category 2 — appointment clinically indicated within 90 days

  • disabling migraine headaches despite trials of at least two first line migraine preventive medications
    • a third prophylactic agent and headache diary should be commenced while awaiting review
  • cluster headache/trigeminal autonomic cephalgia in remission but needing ongoing assessment or management

Category 3 — appointment clinically indicated within 365 days

  • headaches not meeting above criteria where specialist input is required for diagnosis or management

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • complete past medical history
  • current medication list including non-prescription medication, herbs and supplements
  • alcohol and other drugs history
  • list all treatments trialled including maximum dose reached and duration of therapy for migraines or other episodic disabling headaches
  • clinical history including:
    • onset and duration of headaches
    • frequency of headaches
    • pain description including location and quality
    • associated functional impairment
    • associated features for example, autonomic features, vomiting, photophobia
    • screening neurological examination

Additional information to assist triage categorisation

  • complete blood examination (CBE)
  • electrolytes, urea, creatinine (EUC)
  • liver function tests (LFTs)
  • C-reactive protein (CRP)
  • erythrocyte sedimentation rate (ESR)
  • neuroimaging

In cases of suspected intracranial hypertension this should be performed prior to referral to exclude emergency cause of headache. Magnetic resonance imaging (MRI)/magnetic resonance venography brain is preferred but may not be accessible in some cases, in which a computed tomography (CT) brain with venogram should be considered.

Please provide details of neuroimaging done including radiology provider and accession number.

Clinical management advice

Features of raised intracranial pressure may include:

  • severe and increasing headaches
  • headaches worse in the morning
  • headache exacerbated by coughing, sneezing, straining or bending forwards
  • papilloedema
  • pulsatile tinnitus
  • visual symptoms – including transient reduction in vision with straining

In the case of suspected raised intracranial pressure but without any criteria for referral to emergency:

  • arrange urgent eye examination by an ophthalmologist/optometrist
  • arrange urgent cerebral imaging to exclude space occupying lesion or cerebral venous sinus thrombosis.

If features of raised intracranial pressure with normal cerebral imaging and normal neurological examination, consider idiopathic intracranial hypertension and refer urgently to neurology for consideration of investigation and management  see ‘exclusions and triage categories – category 1'.

Not all referrals require consultation with a neurologist and patients may be reviewed in advanced practice nurse led clinics where medically appropriate. Nurse led clinics are part of best evidence-based practice and have been shown to reduce patient wait times, increase consultation duration, increase patient engagement and satisfaction; improve communication and provide access to tailored advice on self-management of disease and illness.

Category 3 referrals are accepted at the discretion of the triaging clinician. If you are concerned that your patient requires specialist review, but the referral is declined, you are encouraged to contact the triaging clinician to discuss your concerns.

If the patient you are referring requires urgent attention and/or fulfils category 1 triage criteria, it is strongly recommended that you contact the outpatient department to ensure your referral has been received.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.