Headaches associated with Ophthalmology concerns

 

Introduction

In the context of headaches, if there is a suspicion of intracranial hypertension or acute angle-closure glaucoma, a referral to Ophthalmology should be considered as per the guidelines below.

 

In scope:           

Headaches and suspicion of intracranial hypertension or acute angle-closure glaucoma, or other ophthalmology concerns

 

Not in scope:      

Headaches without any signs or symptoms of intracranial hypertension or acute angle-closure glaucoma, or any other ophthalmology concerns

 

Red Flag Features

This list is not exhaustive

• New sudden-onset severe headache
   
• Associated features such as fever, impaired consciousness, seizure, neck stiffness, photophobia may indicate central nervous system infection¹
  
  
• Papilloedema or other features of raised intracranial pressure
  • severe headaches, daily headaches
  • headaches with postural or diurnal variation
  • headaches with nausea and vomiting
  • headaches exacerbated by Valsalva Manoeuvre
  • associated tinnitus
  • visual disturbance on bending forward
• Abnormal neurological assessment or mental state
   
• New-onset headache in a person aged over 50 years
   
• Trauma

 

Management Optimisation

Consider managing headache in the absence of red flag features in Primary Care.

• Guidance on Headache Assessment
  
  
• Guidance on Headache Management

 

Advice and Guidance

Please send advice and guidance requests to Ophthalmology via eRS

 

Investigations required prior to referral

None, but please include opticians report if available

 

Referral instructions

Red Flags:

If any red flag features, consider same day emergency medical admission or discussion with Acute GPs, or Consultant Neurologist of the day depending on clinical need, this is irrespective of any suspicion of papilloedema.

 

Emergency Eye Casualty Referral:

• Suspicion of acute angle-closure glaucoma:
  • Over 50 years of age
  • Severe frontal or orbital pain
  • Red eye
  • Associated nausea and vomiting
• Any other emergency eye condition requiring eye casualty referral

This list is not exhaustive

 

Routine Ophthalmology Referral:

In the absence of red flags, emergency and urgent suspected Ophthalmology and Neurology pathology:

• Optician requesting second opinion on suspicious optic disc appearances, with no history suggestive of raised intracranial pressure or red flag features
  • Confirm with patient that there is no history suggestive of raised intracranial pressure and no red flags
  • Refer to Ophthalmology A&G with attached opticians report, including a jpeg photo of the optic disc if available

 

• Optician notes history of headache and recommends referral to ophthalmologist
  • Review and obtain history directly from patient and refer to guidance above prior to any Ophthalmology referral. Please see headache guideline and consider referral to Neurology as appropriate.

 

• If a "just in case" opinion on optic disc appearance is required in the absence of red flag features
  • Request optic disc imaging via Advice and Guidance. Ophthalmology will then organise for urgent optic disc imaging and deliver a consultant report. Please note the consultant will only be reporting on the optic disc imaging and will not have reviewed the patient in person. This report can then be used by the referrer in the context of the patient's overall clinical picture.

 

(Please note optometrists are not required to have urgent appointments available.  NHS eye tests are not a universal entitlement in England, some patients will have to pay for their eye test privately.  More information on eligibility of NHS-funded sight tests is available here)

 

Supporting Information

For Professionals

• Scenario: Headache - diagnosis | Diagnosis | Headache - assessment | CKS | NICE
• Scenario: Acute angle closure and angle closure glaucoma | Management | Glaucoma | CKS | NICE

 

For Patients

• Free NHS eye tests and optical vouchers - NHS

 

References

• Scenario: Headache - diagnosis | Diagnosis | Headache - assessment | CKS | NICE

 

Page review information

Date reviewed                   12 September 2025       

Next review due                12September 2027     

Speciality Lead GP            Dr Kate Northridge                       

Contributor                        Dr David Jones, Consultant Ophthalmologist Royal Cornwall Hospital