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Headaches/migraine

PAEDIATRIC

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.


Adult

Stroke/transient ischaemic attack (TIA)

  • Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
  • New acute symptoms

Progressive loss of neurological function

  • Acute onset severe:
    • ataxia
    • vertigo
    • visual loss
  • Acute severe exacerbation of known MS

Seizures/epilepsy

  • Status epilepticus/epilepsy with concerning features:
    • first seizure
    • focal deficit post-ictally
    • seizure associated with recent trauma
    • persistent severe headache > 1 hour post-ictally
    • seizure with fever

Headache/migraine

  • Headache with concerning features:
    • sudden onset/thunderclap headache
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • first severe headache age > 50 years
    • severe headache associated with recent head trauma
    • recent onset headaches in young obese females
    • headaches with papilledema
    • >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected

Movement disorders

  • Ocular

Other referrals to emergency

  • Altered level of consciousness
  • Bilateral limb weakness with or without bladder and/or bowel dysfunction
  • Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
  • Delirium/sudden onset confusion with or without fever

 

Paediatric

Seizures/epilepsy

  • New onset seizures that require emergency care/advice
  • Status epilepticus (convulsive or non-convulsive)
  • Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
  • New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
  • Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
  • High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
  • Neonate / infant (<12-month-old) with epileptic seizure onset

Headaches/migraine

  • Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
  • Headaches that wake at night or headaches immediately on wakening
  • New severe headaches
  • Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
  • Focal neurological features
  • Associated with significant persisting change of personality or cognitive ability or deterioration in school performance

Functional neurological symptoms

  • The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition

Movement disorder

  • Abrupt onset or deterioration of a movement disorder
  • Acute onset of ataxia / chorea
  • Impairment of function i.e. walking, attend school

Hypotonic infant

  • Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
  • Feeding difficulties with weight loss

Gait abnormality, isolated motor delay or focal weakness

  • Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
  • Acute onset focal weakness (suspected stroke – call 000)
  • Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
  • Feeding or swallowing difficulties
  • Acute foot drop or acute onset focal neuropathy

Stroke

  • Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)

Other neurological conditions

  • Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
  • Acute encephalopathy, acute confusional state, altered level of consciousness
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
  • Referral from a health practitioner other than a General Paediatrician may be accepted if there is limited access to public Paediatric services in the patients’ local area
  • A change in patient circumstance (such as condition deteriorating) may affect the urgency categorisation and should be communicated as soon as possible.
  • Refer to local care pathway
  • Refer to General Paediatrics Headache CPC
  • Neuroimaging is not usually recommended when the neurological examination is normal. MRI is a more appropriate investigation than CT if imaging is required

Clinical Resources

Patient resources

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Recurrent hemiplegic migraine
  • Category 2
    (appointment within 90 calendar days)
    • Idiopathic intracranial hypertension referred by a Paediatrician where there is diagnostic uncertainty that headache is due to IIH, failure of response to treatment and no visual impairment on perimetry (no indication for urgent neurosurgical shunting).
    • Migraine that has failed two (2) preventative medications
    • Missing significant amounts of school due to headaches
    • Suspicion of medication overuse
  • Category 3
    (appointment within 365 calendar days)
    • No category 3 criteria

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Detailed history of headaches
    • how long has the patient been getting headaches?
    • what is their frequency and duration?
    • is the child missing school (how many days per month) or is normal daily activity limited?
    • is there associated symptoms (vomiting, light/sound sensitivity)?
  • BP (right arm, with appropriately sized cuff)
  • Current medication history, efficacy (including over-the-counter preparations)
  • Neurological examination including fundoscopy

3. Additional referral information Useful for processing the referral

Highly desirable Information – may change triage category

  • Exacerbating and relieving factors
  • Reason for presentation currently
  • Details of previous specialist assessment
  • Headache diary
  • If the child is in foster care, please provide the name and regional office for the Child Safety Officer who is the responsible case manager.

Desirable Information- will assist at consultation.

  • Other past medical history
  • Immunisation history
  • Developmental history
  • Significant psychosocial risk factors (especially parents mental health, family violence, housing and financial stress, department of child safety involvement)
  • Height/weight/head circumference and growth charts with prior measurements if available.
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology
  • Any relevant laboratory results or medical imaging reports, urinalysis result
    If neuroimaging has been done, arrange image transfer to PACS at the hospital the patient is being referred to, with the imaging reports. If electronic imaging transfer is not available, then a CD of the neuroimaging and report should be sent to the neurologist named in the referral.

4. Request

Patient's 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

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

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.)
  • Please note that 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 becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • 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.