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How and when to refer patients diagnosed with primary headache and craniofacial neuralgia in the emergency department or primary care: Recommendations of the Spanish Society of Neurology's Headache Study Group
Cómo y cuándo derivar un paciente con cefalea primaria y neuralgia craneofacial desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Española de Neurología
A.B. Gago-Veigaa,
Corresponding author
dra.anagago@gmail.com

Corresponding author.
, D. García-Azorínb, N. Mas-Salac, C.M. Ordásd, M. Ruiz-Piñerob, M. Torres-Ferrúse,f, S. Santos-Lasaosag, J. Viguera Romeroh, P. Pozo-Rosiche,f
a Unidad de Cefaleas, Servicio de Neurología, Instituto de Investigación Sanitaria Princesa, Hospital Universitario de la Princesa, Madrid, Spain
b Unidad de Cefaleas, Hospital Clínico Universitario de Valladolid, Spain
c Servicio de Neurología, Hospital Universitario Sant Joan de Déu, Fundación Althaia, Manresa, Barcelona, Spain
d Servicio de Neurología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
e Unidad de Cefalea, Servicio de Neurología, Hospital Universitari Vall d’Hebron, Barcelona, Spain
f Grupo de Investigación en Cefalea, VHIR, Universitat Autònoma Barcelona, Spain
g Unidad de Cefaleas – Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
h Unidad Gestión Clínica de Neurología, Hospital Virgen Macarena, Sevilla, Spain
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Differentiating characteristics of the various trigeminal autonomic cephalalgias&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The Spanish Society of Neurology&#39;s Headache Study Group &#40;GECSEN&#41; has detected that patients are attending consultation for headache without having undergone the necessary complementary tests or followed the appropriate care circuits&#44; and are sometimes referred at an inopportune time or without the necessary level of urgency&#47;priority&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We have therefore drafted a series of consensus recommendations based on published scientific evidence and our own experience&#44; establishing protocols for the referral of patients with primary headache and&#47;or craniofacial neuralgias from emergency or primary care &#40;PC&#41; departments&#46; These recommendations are general and will require adaptation to the specific circumstances of each centre&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">These are practical guidelines addressing differential diagnosis&#44; studies to be requested&#44; and how&#47;when to refer&#46; For a more detailed study of the different types of headache&#44; we recommend consulting GECSEN&#39;s Official Clinical Practice Guidelines for Headache&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> which is available online at the study group&#39;s webpage &#40;gecsen&#46;sen&#46;es&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">These guidelines were drafted with the collaboration of young neurologists with experience in treating headaches&#46; For practical reasons&#44; the recommendations are divided into 2 publications&#58; the present work&#44; focusing on primary headache and craniofacial neuralgias&#44; and another which addresses secondary headache and neuralgias&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary headaches addressed are&#58; migraine&#44; tension-type headaches&#44; trigeminal autonomic cephalalgias&#44; cough headaches&#44; exercise headaches&#44; headaches associated with sexual activity&#44; stabbing headaches&#44; nummular headaches&#44; hypnic headaches&#44; new daily persistent headaches&#44; and craniofacial neuralgias&#46; We present each type of headache&#44; with a brief description of the diagnostic criteria according to the International Headache Society&#39;s International Classification of Headache Disorders &#40;ICHD-3 beta&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> the most important differential diagnoses to be considered&#44; and tables illustrating the protocols for action and referral from emergency departments and PC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Recommendations</span><p id="par0030" class="elsevierStylePara elsevierViewall">The most important task when assessing patients with headache&#44; whether in PC or at the emergency department&#44; is to confirm that the patient has no alarm symptoms &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Following this&#44; we can continue assessing the patient and determining how to approach treatment&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Migraine with and without aura</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Episodic migraine</span><p id="par0035" class="elsevierStylePara elsevierViewall">According to the IHCD-3 beta criteria&#44; episodic migraine is a recurring headache with episodes lasting 4-72<span class="elsevierStyleHsp" style=""></span>hours&#44; and is unilateral&#44; pulsatile&#44; of moderate or severe intensity&#44; aggravated by physical activity&#44; and associated with nausea&#47;vomiting and&#47;or photo- or phonophobia&#44; and manifests on fewer than 15 days per month&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> Status migrainosus is defined as a migraine attack lasting more than 72<span class="elsevierStyleHsp" style=""></span>hours and which is refractory to intravenous pharmacological treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> Symptoms may or may not be associated with the presence of aura&#46; The following are grounds to suspect atypical aura&#58; sudden onset&#44; predominance of symptoms of motor involvement &#40;hemiparesis&#41; or negative visual symptoms &#40;loss of sight&#47;hemianopsia&#41;&#44; duration greater than 60<span class="elsevierStyleHsp" style=""></span>min&#44; first episode suggestive of aura but not accompanied by headache or visual symptoms&#44; first episode at later ages &#40;&#62;50&#41;&#44; history of vascular risk factors and&#47;or absence of a family history of migraine &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1&#8211;6</span></a> Patients attending the emergency department for headaches may present a wide range of visual symptoms&#59; both neurological and ophthalmic pathologies must be ruled out &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Chronic migraine</span><p id="par0040" class="elsevierStylePara elsevierViewall">A headache manifesting 15 or more days per month for over 3 months&#44; showing characteristics of migraine headache with or without aura on at least 8<span class="elsevierStyleHsp" style=""></span>days&#47;month&#46; The patient may also meet diagnostic criteria for medication-overuse headache&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> It is very important to consider modifiable risk factors for transformation to chronic migraine&#44; such as overuse of analgesics or caffeine&#44; mood disorders&#44; sleep apnoea&#44; hormonal disorders&#44; or overweight and obesity &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Tension-type headache</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Episodic tension-type headache</span><p id="par0045" class="elsevierStylePara elsevierViewall">Headache manifesting fewer than 15 days per month&#44; which is bilateral&#44; oppressive&#44; of mild to moderate intensity&#44; lasts from minutes to days&#44; is not aggravated by physical activity&#44; and which may be associated with mild nausea or photo- or phonophobia &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Chronic tension-type headache</span><p id="par0050" class="elsevierStylePara elsevierViewall">Headache with the characteristics described above&#44; but presenting on 15 or more days per month&#44; for over 3 months &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Trigeminal autonomic cephalalgias</span><p id="par0055" class="elsevierStylePara elsevierViewall">Trigeminal autonomic cephalalgias &#40;TACs&#41; are a group of conditions which typically cause a very intense&#44; unilateral pain associated with ipsilateral autonomic symptoms in the face&#46; Symptoms include tearing&#44; conjunctival hyperaemia&#44; ptosis&#44; miosis&#44; rhinorrhoea&#44; a sensation of nasal congestion&#44; perspiration&#44; rubefaction&#44; and a sensation of the ears being blocked&#46; Another characteristic symptom may be anxiety during the episode&#44; particularly in cluster headaches&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;7</span></a> All types of TAC present as attacks alternating with periods of remission&#44; with the exception of chronic forms and hemicrania continua&#44; in which there is a persistent&#44; hemicranial background pain&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The group includes various conditions which are clinically differentiated by the duration and frequency of episodes&#44; with each condition showing a specific response to different treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">8</span></a> This group also includes headaches&#58; short-lasting unilateral neuralgiform headache&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9&#8211;11</span></a> paroxysmal hemicrania&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">12&#44;13</span></a> cluster headache&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a> and hemicranea continua<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">15&#44;16</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">These conditions are so disabling that an &#8220;open doors&#8221; approach is recommended for these patients&#44; as early intervention at the beginning of a new period of episodes can prevent it from becoming chronic and improve the patient&#39;s quality of life&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although they are considered to be primary headaches&#44; in all TACs&#44; cases have been described with symptoms such as trigeminal vascular compression in SUNCT&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> In new-onset headache&#44; generally associated with other neurological symptoms&#44; there are published cases of such vascular pathologies as dissection and perivascular tumours&#44; sinusitis&#44; pituitary gland tumours&#44; sinus thrombosis&#44; vascular fistulas&#44; and ophthalmic pathologies &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Other primary headaches</span><p id="par0075" class="elsevierStylePara elsevierViewall">This group is heterogeneous&#46; In a patient&#39;s first episode&#44; urgent neuroimaging study is recommended in order to rule out severe secondary headache&#46; Patients attending consultation for recurring episodes and not presenting alarm signs can be prioritised for neurology studies &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Primary cough headache</span><p id="par0080" class="elsevierStylePara elsevierViewall">A primary headache caused by coughing&#44; with no other intracranial structural abnormalities&#46; People aged below 40 are rarely affected&#46; It predominantly affects men&#44; and is responsive to indomethacin&#46; Duration is short &#40;seconds to minutes&#41;&#44; with onset immediately or a few seconds after coughing or other Valsalva manoeuvres&#44; such as when lifting weights&#46; It is typically bilateral and occipital or frontal&#44; acute with moderate to severe intensity&#44; and stabbing or explosive &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;17</span></a></p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Headache triggered by coughing is secondary in 20&#37; of cases&#44; typically caused by Chiari malformation type 1 or posterior fossa lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">18&#44;19</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Primary exercise headache</span><p id="par0090" class="elsevierStylePara elsevierViewall">Pain is triggered by intense and&#47;or prolonged physical exercise&#46; Young men with migraine are predominantly affected&#46; Headache occurs at peak of exercise and remits with rest&#46; Pain is typically pulsatile or stabbing&#44; lasting less than 48<span class="elsevierStyleHsp" style=""></span>hours&#44; and may be accompanied by migraine symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In 80&#37; of cases&#44; recurrent headaches associated with exercise are primary&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a> Cardiac ischaemia &#40;cardiac cephalalgia&#41; must be ruled out in older patients and patients with cardiovascular risk factors or a history of ischaemic heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> Cases have been described of exercise headaches secondary to pheochromocytoma&#44; intracranial hyper- or hypotension&#44; or venous sinus thrombosis&#59; clinical judgement should determine the need for investigation&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Primary headache associated with sexual activity</span><p id="par0100" class="elsevierStylePara elsevierViewall">Headache occurs only during sexual activity&#46; Location is occipital and bilateral&#59; pain is intense and occurs at climax or as sexual excitement increases&#44; improving when the activity stops &#40;within 24<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; It typically occurs in middle-aged adults&#44; predominantly in men&#44; and co-presents with migraine&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Primary sexual headache is usually recurrent&#46; Cases have been described of sexual headache secondary to subarachnoid haemorrhage&#44; arterial dissection&#44; reversible cerebral vasoconstriction syndrome&#44; or arterial hypertension&#46; These conditions should particularly be suspected in women&#44; people older than 40-50 years&#44; and patients with prolonged episodes&#44; loss of consciousness&#44; or nuchal rigidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">18&#44;19</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Primary thunderclap headache</span><p id="par0110" class="elsevierStylePara elsevierViewall">Clinical presentation is similar to that of aneurysm rupture&#44; and occurs repetitively without the presence of any intracranial structural lesion&#46; Onset is sudden&#44; reaching maximum intensity in less than 60<span class="elsevierStyleHsp" style=""></span>seconds&#44; and can last hours or even weeks&#46; Pain is spontaneous or triggered by exercise&#44; sexual activity&#44; or hyperventilation&#46; Location is typically occipital&#59; headache may be accompanied by nausea and vomiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;17</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Evaluation of potential secondary causes must be swift and exhaustive&#59; it is essential to rule out intracerebral haemorrhage&#44; subarachnoid haemorrhage&#44; cerebral venous thrombosis&#44; vascular malformations&#44; arterial dissection&#44; reversible cerebral vasoconstriction syndrome&#44; pituitary apoplexy&#44; meningitis&#44; colloid cyst of the third ventricle&#44; CSF hypotension&#44; and acute sinusitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#44;21</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Primary stabbing headache</span><p id="par0120" class="elsevierStylePara elsevierViewall">Headache takes the form of transitory stabs of pain&#44; short in duration &#40;seconds&#41;&#44; with irregular frequency &#40;one or multiple per day&#41; and variable cranial location&#44; and is not accompanied by autonomic symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2&#44;17</span></a> The condition is common&#44; predominantly affecting young women&#44; and co-presents with migraine&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21&#44;22</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Main differential diagnosis should consider other primary headaches&#44; such as SUNCT&#44; paroxysmal hemicrania&#44; and trigeminal neuralgia&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Nummular headache</span><p id="par0130" class="elsevierStylePara elsevierViewall">Cranial pain in a fixed&#44; sharply contoured&#44; circular or oval area&#44; measuring 1-6<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46; Pain is oppressive or stabbing&#44; mild to moderate in intensity and associated with intense paroxysms&#46; Half of patients show some kind of sensory alteration &#40;allodynia&#44; hypoaesthesia&#44; paraesthesia&#41;&#44; or even dermatologic alterations &#40;alopecia&#44; change in hair colour&#44; or skin atrophy&#41;&#46; Around 10&#37; of patients have a history of local trauma&#46; Nummular headache can occur at any age and affects women more than men&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Secondary cases have been described due to&#58; fusiform aneurysm of a branch of the superficial temporal artery&#44; cranial fibrous dysplasia&#44; Paget disease&#44; meningioma&#44; arachnoid cysts&#44; insect bites&#44; and pituitary adenoma resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">24&#44;25</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Hypnic headache</span><p id="par0140" class="elsevierStylePara elsevierViewall">This condition is uncommon&#44; typically presents at older ages and predominantly in women&#44; and is mainly characterised by occurring exclusively during sleep&#46; Patients typically experience one attack per night&#44; lasting from 15<span class="elsevierStyleHsp" style=""></span>minutes to 4<span class="elsevierStyleHsp" style=""></span>hours&#44; 10 or more nights per month&#59; pain commonly occurs at the same time every night &#40;mainly between 2 and 4<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">am</span>&#41;&#46; Patients report a moderate&#44; dull pain which is frontotemporal and bilateral or holocranial&#46; It can be associated with mild vegetative symptoms &#40;nausea&#41;&#46; Patients often respond to pain by occupying themselves with some peaceful activity&#44; unlike with migraine &#40;where they tend to seek rest&#41; and TACs &#40;which are generally accompanied by agitation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Cases have been described of hypnic headache secondary to posterior fossa or brainstem lesions &#40;meningioma&#44; cerebellar haemangioblastoma&#41; and pituitary gland lesions &#40;non-functioning pituitary macroadenoma&#41;&#44; sleep apnoea-hypopnoea syndrome &#40;SAHS&#41;&#44; nocturnal arterial hypertension&#44; withdrawal from such drugs as lithium or ACE inhibitors&#44; or symptomatic medication overuse&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">26&#8211;28</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">New persistent daily headache</span><p id="par0150" class="elsevierStylePara elsevierViewall">Headache occurs every day from onset&#44; for at least 3 months&#46; Patients very frequently remember the precise day and circumstances of pain onset&#44; although it is possible in fewer than half of cases to identify a trigger &#40;infection&#44; stressful event&#44; surgery&#44; substance exposure&#41;&#46; Semiological characteristics are not relevant in defining this type of headache&#46; It is more common in women&#44; and can manifest at any age&#44; particularly in the second and third decades of life&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">It is essential to rule out secondary causes&#44; such as intracranial hypertension &#40;idiopathic or secondary&#41; or CSF hypotension&#44; overuse of symptomatic medication&#44; chronic meningitis&#44; chronic subdural haematoma&#44; cervical artery dissection&#44; cerebral venous thrombosis&#44; arteriovenous malformation&#44; dural arteriovenous fistula&#44; giant cell arteritis&#44; and cervicogenic headache&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">19&#8211;31</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Craniofacial neuralgias</span><p id="par0160" class="elsevierStylePara elsevierViewall">Neuralgias have been described both in the main nerve trunks and in the terminal branches of these nerves&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Trigeminal neuralgia</span><p id="par0165" class="elsevierStylePara elsevierViewall">This is the most frequent type of neuralgia&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> It is characterised by brief &#40;less than 2<span class="elsevierStyleHsp" style=""></span>minutes&#41;&#44; very intensely painful&#44; stabbing or electric-shock-like paroxysms&#44; triggered by stimuli including chewing or local palpation&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">2</span></a> There is usually a refractory period during which a new attack cannot be triggered&#46; The second and third branches are most frequently affected&#44; with first branch involvement being very rare &#40;&#60;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Classic trigeminal neuralgia accounts for 90&#37; of cases&#44; and is caused by a vascular kink compressing the nerve root&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> In cases where exploration reveals alterations such as local hypoaesthesia&#44; abolished corneal reflex&#44; or alterations in other cranial nerves&#44; secondary causes &#40;slow-growing tumours&#44; cranial base abnormalities&#44; vascular malformations&#44; demyelinating lesions&#44; or brainstem stroke&#41; should be suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Neuralgia has been described in the terminal branch of the trigeminal nerve&#44; with a burning&#44; stinging pattern of pain&#46; These are supra- and infraorbital neuralgia&#44; mental nerve neuralgia&#44; nasociliary neuralgia&#44; auriculotemporal neuralgia&#44; supra- and infratrochlear neuralgia and lacrimal neuralgia&#46; The possibility of tumoural aetiology should be accounted for&#44; particularly in the case of mental and infraorbital nerve involvement&#44; &#40;numb chin and numb cheek syndrome&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Nervus intermedius neuralgia</span><p id="par0180" class="elsevierStylePara elsevierViewall">Neuralgia caused by alterations affecting the seventh cranial nerve and characterised by attacks of acute pain deep in the ear canal&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Typical triggers include tragal pressure&#44; cold&#44; noise&#44; and chewing&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Glossopharyngeal neuralgia</span><p id="par0185" class="elsevierStylePara elsevierViewall">Glossopharyngeal neuralgia is caused by irritation of the ninth cranial nerve&#44; in the majority of cases due to a kink in the ipsilateral PICA&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Patients experience pain in the periauricular region and&#47;or the posterior third of the tongue&#44; the pharynx&#44; and the tonsillar region&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Typical triggers are coughing&#44; swallowing&#44; sneezing&#44; or yawning&#46; In addition to paroxysms of typically lancinating pain&#44; a burning or dull pain may be experienced between attacks&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a> Secondary causes include demyelinating lesions&#44; local tumours&#44; tonsillar abscesses&#44; Chiari malformations and vascular aneurysms&#46; It is important for differential diagnosis to consider Eagle syndrome&#59; this syndrome features pharyngeal pain&#44; which may be paroxysmal and triggered by swallowing&#44; and may be reproduced with pressure on the ipsilateral tonsillar fossa&#46; This syndrome is caused by calcification of the stylohyoid ligament&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Superior laryngeal neuralgia</span><p id="par0190" class="elsevierStylePara elsevierViewall">This neuralgia affects the tenth cranial nerve&#46; It is characterised by attacks of lancinating pain in the anterolateral region of the neck&#44; triggered by swallowing&#44; turning of the neck&#44; shouting&#44; or singing&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Occipital neuralgias</span><p id="par0195" class="elsevierStylePara elsevierViewall">Occipital neuralgias are characterised by continuous or paroxysmal pain in the occipital region&#44; often radiating to the upper parietal or even the frontal region&#46; Typically&#44; there is local sensitivity which reproduces the pain&#46; These neuralgias are often associated with pathologies affecting the neck&#46; They most commonly affect the greater occipital nerve&#44; although cases have also been described in the lesser occipital and third occipital nerves&#46;</p></span></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">Better understanding of complementary tests&#44; of criteria for referral to emergency departments and for admission&#44; of which specialists should evaluate patients&#44; and of how referral should be sought&#44; will enable better treatment of patients with headache&#44; both from PC physicians and emergency departments&#46; However&#44; this demonstrates many of the shortfalls seen in a great majority of centres at the national level&#44; which lack headache units or the sufficient specialist clinics to guarantee that patients be managed with the necessary level of priority and that the proper tests are requested&#46; Referring to official recommendations in order to optimise these issues will help to improve quality of life for patients with such a debilitating condition as headache&#44; which on occasions also conceals less benign processes&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Migraine with and without aura"
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                  "identificador" => "sec0020"
                  "titulo" => "Episodic migraine"
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                  "identificador" => "sec0025"
                  "titulo" => "Chronic migraine"
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              "titulo" => "Tension-type headache"
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                  "identificador" => "sec0035"
                  "titulo" => "Episodic tension-type headache"
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                  "titulo" => "Chronic tension-type headache"
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              "titulo" => "Trigeminal autonomic cephalalgias"
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              "titulo" => "Other primary headaches"
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                0 => array:2 [
                  "identificador" => "sec0055"
                  "titulo" => "Primary cough headache"
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                1 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Primary exercise headache"
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                2 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Primary headache associated with sexual activity"
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                3 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Primary thunderclap headache"
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                4 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Primary stabbing headache"
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                5 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Nummular headache"
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                6 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Hypnic headache"
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                  "titulo" => "New persistent daily headache"
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              "titulo" => "Craniofacial neuralgias"
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                  "identificador" => "sec0100"
                  "titulo" => "Trigeminal neuralgia"
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                  "titulo" => "Nervus intermedius neuralgia"
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                  "identificador" => "sec0110"
                  "titulo" => "Glossopharyngeal neuralgia"
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                3 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Superior laryngeal neuralgia"
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                4 => array:2 [
                  "identificador" => "sec0120"
                  "titulo" => "Occipital neuralgias"
                ]
              ]
            ]
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          "identificador" => "sec0125"
          "titulo" => "Conclusions"
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          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2017-07-24"
    "fechaAceptado" => "2017-08-01"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Headache"
            1 => "Neuralgia"
            2 => "Primary care"
            3 => "Emergency department"
            4 => "Complementary test"
            5 => "Patient referral"
          ]
        ]
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            0 => "Cefalea"
            1 => "Neuralgia"
            2 => "Atenci&#243;n primaria"
            3 => "Urgencias"
            4 => "Pruebas complementarias"
            5 => "Derivaci&#243;n"
          ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">When a patient is diagnosed with primary headache or craniofacial neuralgia in the emergency department or in primary care&#44; and is referred to a neurologist due to the complexity of the case&#44; it is useful to know whether additional examination should be sought and the priority &#40;urgent&#44; preferential&#44; or normal&#41; with which the patient should be seen&#46; This will avoid unnecessary delays in patients with disabling headache and where organic causes are suspected&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In order to issue recommendations on this matter&#44; the Spanish Society of Neurology&#39;s Headache Study Group has decided to create a series of agreed recommendations constituting a referral protocol for patients with headache and&#47;or craniofacial neuralgia&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Development</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with the Spanish Society of Neurology&#39;s Headache Study Group Executive Committee&#46; For practical reasons&#44; the document was divided into 2 articles&#58; this first article focuses on primary headaches and craniofacial neuralgias and the second on secondary headaches&#46; In order for the recommendations to be helpful for daily practice they follow a practical approach&#44; with tables summarising referral criteria&#44; examinations to be performed&#44; and referral to other specialists&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We hope to offer a guide and tools to improve decision-making regarding patients with headache&#44; identifying complementary tests to prioritise and referral pathways to be followed&#44; in order to avoid duplicated consultations and delayed diagnosis and treatment&#46;</p></span>"
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          0 => array:2 [
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            "titulo" => "Introduction"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cuando tras una correcta anamnesis y exploraci&#243;n neurol&#243;gica se diagnostica a un paciente con una cefalea primaria o una neuralgia craneofacial en urgencias o atenci&#243;n primaria y se decide derivar a neurolog&#237;a por complejidad es &#250;til conocer si adem&#225;s se deber&#237;an solicitar exploraciones complementarias y la preferencia &#40;urgente&#44; preferente o normal&#41; con la que se deber&#237;a derivar para que el paciente llegue a la consulta del neur&#243;logo sin demoras innecesarias en pacientes con dolores incapacitantes o con sospecha de organicidad&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Por este motivo&#44; el Grupo de Estudio de Cefalea de la Sociedad Espa&#241;ola de Neurolog&#237;a&#44; ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivaci&#243;n de pacientes con cefalea y&#47;o neuralgias craneofaciales&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Desarrollo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se ha contactado con neur&#243;logos j&#243;venes con inter&#233;s y experiencia en cefalea y con la Junta Directiva del Grupo de Estudio de Cefalea de la Sociedad Espa&#241;ola de Neurolog&#237;a que han desarrollado este documento que&#44; por razones pr&#225;cticas&#44; se ha dividido en 2 art&#237;culos&#46; Esta primera centrada en las cefaleas o neuralgias craneofaciales primarias y una segunda que se focaliza en las cefaleas secundarias&#46; El enfoque es pr&#225;ctico con tablas que resumen los criterios de derivaci&#243;n con exploraciones complementarias y otros especialistas a los que derivar&#44; para que sea &#250;til y facilite su uso en nuestra pr&#225;ctica asistencial diaria&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Esperamos ofrecer una gu&#237;a y herramientas para mejorar la toma de decisiones ante un paciente con cefalea&#44; valorando exploraciones a priorizar y qu&#233; circuitos seguir para as&#237; evitar la duplicaci&#243;n de consultas y retrasos en el diagn&#243;stico y en el tratamiento&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0060">Please cite this article as&#58; Gago-Veiga AB&#44; Garc&#237;a-Azor&#237;n D&#44; Mas-Sala N&#44; Ord&#225;s CM&#44; Ruiz-Pi&#241;ero M&#44; Torres-Ferr&#250;s M&#44; et al&#46; C&#243;mo y cu&#225;ndo derivar un paciente con cefalea primaria y neuralgia craneofacial desde Urgencias y Atenci&#243;n Primaria&#58; recomendaciones del Grupo de Estudio de Cefalea de la Sociedad Espa&#241;ola de Neurolog&#237;a&#46; Neurolog&#237;a&#46; 2020&#59;35&#58;176&#8211;184&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CT&#44; computed tomography&#59; ECG&#44; electrocardiogram&#59; ESR&#44; erythrocyte sedimentation rate&#59; MRI&#44; magnetic resonance imaging&#59; PC&#44; primary care&#59; SAHS&#44; sleep apnoea-hypopnoea syndrome&#59; TMJ&#58; temporomandibular joint&#59; TSH&#44; thyroid stimulating hormone&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Migraine</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
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                  \t\t\t\t">Complementary tests</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">From emergency department to neurology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Urgent cranial CT scan<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>deferred brain MRI if <span class="elsevierStyleItalic">first episode of aura&#47;atypical aura&#47;refractory status migrainosus&#47;red flags</span>Neurosonology and&#47;or CT-angiography<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>echocardiogram&#47;Holter-ECG<a class="elsevierStyleCrossRefs" href="#tblfn0005"><span class="elsevierStyleSup">a&#44;b</span></a> if <span class="elsevierStyleItalic">first episode of atypical aura without headache</span>Lumbar puncture if <span class="elsevierStyleItalic">atypical aura with&#47;without fever and normal neuroimaging findings</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">From PC to neurology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polysomnography if <span class="elsevierStyleItalic">SAHS is suspected</span>ESR&#44; TSHHypercoagulability study if <span class="elsevierStyleItalic">atypical and&#47;or prolonged aura</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to emergency department and&#47;or admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atypical or prolonged auraRefractory status migrainosusSecondary cause is suspectedPainkiller cessation following past failure in outpatient care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for outpatient follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary care</span>&#58; low-frequency episodic migraine&#47;evaluation of possible risk factors for transformation to chronic migraine<span class="elsevierStyleItalic">Neurology &#40;normal priority&#41;</span>&#58; high-frequency episodic migraine&#47;prolonged attacks&#47;habitual drugs contraindicated<span class="elsevierStyleItalic">Neurology &#40;high priority&#41;&#47;headache unit</span>&#58; chronic migraine&#47;frequent and&#47;or atypical auras&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to other specialists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Ophthalmology</span> if atypical visual symptoms<span class="elsevierStyleItalic">Psychiatry</span> if co-presence of significant depression or anxiety disorder<span class="elsevierStyleItalic">Rehabilitation</span> if cervical pain or TMJ dysfunction<span class="elsevierStyleItalic">Maxillofacial surgery</span> if severe TMJ dysfunction<span class="elsevierStyleItalic">Endocrinology</span> if hormonal alteration and&#47;or obesity<span class="elsevierStyleItalic">Pneumology</span> if SAHS is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2289778.png"
              ]
            ]
          ]
          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">To be carried out in the emergency department or the outpatient clinic&#44; depending on availability at the centre&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Depending on clinical presentation&#44; particularly vascular risk factors&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Protocol for action and referral from emergency departments and PC for migraine and aura without headache&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Visual alarm symptom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Opthalmic&#47;neurological pathology to be ruled out&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Painful red eye and reduced visual acuity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Opthalmic disorders&#58; glaucoma&#44; uveitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progressive reduction in visual acuity and&#47;or temporary darkening of vision&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Papilloedema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Proptosis&#47;exophthalmos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Orbital space-occupying lesions&#47;intracranial vascular problems&#47;arteriovenous fistulas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oculomotor palsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Space-occupying&#47;infiltrative&#47;vascular&#47;inflammatory lesions&#59; Tolosa&#8211;Hunt syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Palpebral oedema&#44; palpebral erythema and&#47;or tumefaction &#40;with fever or general discomfort&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Orbital cellulitis&#47;orbital or retroorbital pathology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Decreased visual acuity associated with headache and systemic symptoms in patients aged &#62;50 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Temporal arteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2289777.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Patient with headache and visual alarm symptoms and associated ophthalmic&#47;neurological pathologies to be ruled out&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CT&#44; computed tomography&#59; ESR&#44; erythrocyte sedimentation rate&#59; SAHS&#44; sleep apnoea and hypopnoea syndrome&#59; TMJ&#44; temporomandibular joint&#59; TSH&#44; thyroid stimulating hormone&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Tension-type headache</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complementary tests</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">From emergency department to neurology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cranial CT scan if <span class="elsevierStyleItalic">red flags</span>ESR in elderly patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">From PC to neurology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polysomnography if <span class="elsevierStyleItalic">SAHS is suspected</span>ESR&#44; TSH<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to emergency department and&#47;or admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary cause is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for outpatient follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Primary care</span><span class="elsevierStyleItalic">Neurology &#40;normal priority&#41;</span>&#58; chronic tension-type headache and co-presence of painkiller abuse and&#47;or failed prevention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to other specialists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Psychiatry</span> if co-presence of significant depression or anxiety disorder<span class="elsevierStyleItalic">Rehabilitation</span> if cervical pain or TMJ dysfunction<span class="elsevierStyleItalic">Maxillofacial surgery</span> if severe TMJ dysfunction<span class="elsevierStyleItalic">Pneumology</span> if SAHS is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2289776.png"
              ]
            ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">In patients with chronic tension-type headache&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Protocol for action and referral from emergency departments and PC for tension-type headache&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Trigeminal autonomic cephalalgias</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complementary tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgent brain CT scan if <span class="elsevierStyleItalic">red flags</span>&#59; evaluation of CT-angiography if <span class="elsevierStyleItalic">dissection is suspected</span>Deferred brain MRI&#44; always using FIESTA sequences and MRI-angiography for SUNCT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to emergency department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disabling headacheSecondary cause is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for outpatient follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Headache unit</span> or <span class="elsevierStyleItalic">neurology department &#40;high priority&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to other specialists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Psychiatry</span> if co-presence of significant depression or anxiety disorder&#47;borderline personality disorder&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2289779.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Protocol for action and referral from emergency departments and PC for trigeminal autonomic cephalalgias&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">BP&#44; blood pressure&#59; CSF&#44; cerebrospinal fluid&#59; CT&#44; computed tomography&#59; ESR&#44; erythrocyte sedimentation rate&#59; IM&#44; internal medicine&#59; MRI&#44; magnetic resonance imaging&#59; NPH&#44; nephrology&#59; NS&#44; neurosurgery&#59; PNM&#44; pneumology&#59; SAT&#44; supra-aortic trunks&#59; TSH&#44; thyroid stimulating hormone&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complementary tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Referral for outpatient follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cough headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgent brain CT scan if <span class="elsevierStyleItalic">first episode or red flags&#46; Rule out posterior fossa lesions</span>Deferred brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleHsp" style=""></span>&#8594;<span class="elsevierStyleHsp" style=""></span>A dynamic MRI CSF study and&#47;or gandolinium-enhanced MRI may be considered if <span class="elsevierStyleItalic">tonsillar descent</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Emergency department</span> if first episode and secondary cause is suspected&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Exercise headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgent brain CT scan&#47;CT angiography if <span class="elsevierStyleItalic">first episode or red flags&#46; Rule out SAH</span>Brain MRI and MRI-angiography for recurrent forms<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a>Myocardial markers&#44; catecholamines<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurology &#40;high priority&#41;&#47;headache unit</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sexual headaches&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgent brain CT scan&#47;CT angiography&#46; <span class="elsevierStyleItalic">Rule out SAH</span>Brain MRI&#47;MRI-angiography if <span class="elsevierStyleItalic">red flags</span>Lumbar puncture&#47;ESR&#47;D-dimer<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">IM</span>&#47;<span class="elsevierStyleItalic">NPH</span>&#47;<span class="elsevierStyleItalic">surgery</span>&#47;<span class="elsevierStyleItalic">NS</span><a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thunderclap headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urgent brain CT scan&#47;CT angiography&#46; <span class="elsevierStyleItalic">Rule out SAH</span>Brain MRI&#47;MRI-angiography including SAT if <span class="elsevierStyleItalic">red flags</span>Lumbar puncture&#47;ESR&#47;D-dimer<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary stabbing headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brain CT scan if <span class="elsevierStyleItalic">recurring symptoms or red flags</span>Deferred MRI&#47;MRI-angiography<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurology &#40;normal priority&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nummular headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brain CT scan if <span class="elsevierStyleItalic">recurring symptoms or red flags</span>Deferred brain MRI<a class="elsevierStyleCrossRefs" href="#tblfn0030"><span class="elsevierStyleSup">c&#44;d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurology &#40;high priority&#41;&#47;headache unit</span> if pain is refractory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypnic headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brain CT scan if <span class="elsevierStyleItalic">recurring symptoms or red flags</span>Deferred brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>ESR&#44; TSH<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>Outpatient blood pressure monitoring<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>Polysomnography if <span class="elsevierStyleItalic">other SAHS symptoms are present</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">IM</span>&#47;<span class="elsevierStyleItalic">PNM</span>&#47;<span class="elsevierStyleItalic">NPH</span>&#47;<span class="elsevierStyleItalic">NS</span><a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">New daily headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brain CT scan if <span class="elsevierStyleItalic">recurring symptoms or CT-angiography revealing red flags</span><a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>Deferred brain MRI<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>BP recordESR&#44; TSH<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>Neck X-ray<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a>Lumbar puncture to assess alterations to CSF dynamics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0020"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">With particular attention to the posterior fossa&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">It is essential to rule out space-occupying lesions or vascular malformations&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">In patients selected according to diagnostic suspicion&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0035"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">With particular attention to cerebral vault and extra-axial region&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0040"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">According to findings of complementary tests&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Protocol for action and referral from emergency departments and PC for other primary headaches&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
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          "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">CT&#44; computed tomography&#59; IAC&#44; internal auditory canal&#59; MRI&#44; magnetic resonance imaging&#59; ORL&#44; otorhinolaryngology&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Craniofacial neuralgias</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complementary tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Brain MRI &#40;always&#41;<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">a</span></a>Angiography and 3-D imaging for trigeminal and glossopharyngeal neuralgiaFacial CT scan<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">b</span></a>Neck CT scan&#47;MRI for superior and occipital laryngeal neuralgia if <span class="elsevierStyleItalic">Eagle syndrome is suspected</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to emergency department&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If incapacitating pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral for outpatient follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Neurology &#40;high priority&#41;&#47;headache unit</span> if pain is refractory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Referral to other specialists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Maxillofacial surgery&#44; ORL&#44; neurosurgery</span><a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tblfn0045"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0045">Focusing on posterior fossa and IAC in nervus intermedius neuralgia&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0050"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0050">In selected cases of neuralgia of terminal branches of the trigeminal nerve&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0055"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Depending on type of neuralgia and findings&#46; In glossopharyngeal&#47;laryngeal&#47;nervus intermedius neuralgias&#44; ORL assessment is essential&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Protocol for action and referral from emergency departments and PC for the main craniofacial neuralgias&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:34 [
            0 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Gu&#237;a oficial para el diagn&#243;stico y tratamiento de las cefaleas 2015"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Ezpeleta"
                            1 => "P&#46; Pozo-Rosich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2015"
                        "editorial" => "Editorial Luz&#225;n 5"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Headache Classification Committee of the International Headache Society &#40;IHS&#41;"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "edicion" => "3rd ed&#46; beta version"
                        "fecha" => "2013"
                        "paginaInicial" => "629"
                        "paginaFinal" => "808"
                        "editorial" => "Cephalalgia"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Grupo de Estudio de Cefaleas de la Sociedad Espa&#241;ola de Neurolog&#237;a&#46; Gu&#237;a pr&#225;ctica diagn&#243;stico terap&#233;utica de la Cefalea del adulto y el ni&#241;o en urgencias&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Migra&#241;a otras cefaleas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "V&#46; Mateos-Marcos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
                        "fecha" => "2011"
                        "paginaInicial" => "31"
                        "paginaFinal" => "60"
                        "editorial" => "Elsevier"
                        "editorialLocalizacion" => "Barcelona"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Late-life migraine accompaniments&#58; further experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46;M&#46; Fisher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.str.17.5.1033"
                      "Revista" => array:6 [
                        "tituloSerie" => "Stroke"
                        "fecha" => "1986"
                        "volumen" => "17"
                        "paginaInicial" => "1033"
                        "paginaFinal" => "1042"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3532432"
                            "web" => "Medline"
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Article information
ISSN: 21735808
Original language: English
DOI:10.1016/j.nrleng.2017.08.004
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