Dryland rivers occur over much of Australia's inland and have some of the most variable patterns of flow in the world. Despite their dominance in terms of Australia's river types, dryland rivers have not been the focus of the recent increase in research on indicators of river health, mostly owing to their spatial remoteness and relatively low levels of water resource development and human disturbance. Most rivers in arid and semi-arid regions are ephemeral, and only carry significant flows during the wetter months or following infrequent but intense rainfall events. It is not known which, if any, of the existing approaches to river health assessment can be used to accurately assess the health of these large ephemeral rivers. This paper considers why the standard methods for interpreting the currently-used indicators for river health may need to be adapted for variable systems and suggests the use of trends that recognise natural variation in indicator values for undertaking this.