When to refer a migraine patient to an expert

Refer patients with migraine to an expert when:

• neurological symptoms are prolonged
• the usual headache pattern deteriorates suddenly
• they need acute treatment (analgesics or triptans) for more than 8 to 10 days per month and do not respond to prophylaxis in the usual dose range
• they often need emergency department or hospital treatment or have to take days off work due to migraine
• they have isolated aura without headache
• the diagnosis is uncertain.

Send patients with thunderclap headache (even if they routinely have migraines) for urgent assessment in an emergency department.