Table 5.

Patients likely to be referred to level 3 within optimally structured headache services^a (adapted from [29])

Patients with:

• Refractory disabling headache of any type;

• Cluster headache and other trigeminal autonomic cephalalgias, at first presentation;

• High and low cerebrospinal fluid-pressure headaches;

• Trigeminal and other cranial neuralgias or painful lesions of the cranial nerves;

• Rare primary or secondary headaches;

• Medication-overuse headache involving drugs of dependence, where personality mitigates against withdrawal of medication or where withdrawal attempts have failed;

• Other probable or certain serious secondary headache;

• Headaches with severe physical and/or psychological comorbidities.

Cases of persisting diagnostic uncertainty.

Patients in whom risk of serious underlying disorders demands specialist investigation.

Patients who may participate in specific level-3 research projects (including clinical trials) [66].

^adepending in some cases on the facilities and skills available at level 2