Diagnosis and management of headaches in young people and adults: NICE Guidelines

The following recommendations were identified as priorities for implementation in 2012. In 2015, the evidence was reviewed for the key priority recommendation on prophylactic treatment, but no change was made to the recommended action.

The recommendations have been categorized into Assessment, Diagnosis, and Management. They have been summerised below –

1.1 Assessment

1.1.1Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral:worsening headache with fever,sudden‑onset headache reaching maximum intensity within 5 minutes,new‑onset neurological deficit,new‑onset cognitive dysfunction,change in personality,impaired level of consciousness,recent (typically within the past 3 months) head trauma,headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze,headache triggered by exercise,orthostatic headache (headache that changes with posture),symptoms suggestive of giant cell arteritis,symptoms and signs of acute narrow angle glaucoma,a substantial change in the characteristics of their headache.

1.1.2Consider further investigations and/or referral for people who present with new‑onset headache and any of the following:compromised immunity, caused, for example, by HIV or immunosuppressive drugs,age under 20 years and a history of malignancy,a history of malignancy known to metastasise to the brain,vomiting without other obvious cause.

1.1.3Consider using a headache diary to aid the diagnosis of primary headaches.

1.1.4If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:frequency, duration and severity of headaches,any associated symptoms,all prescribed and over the counter medications taken to relieve headaches,possible precipitants,relationship of headaches to menstruation. [2012]

1.2 Diagnosis

Tension‑type headache, migraine (with or without aura) and cluster headache

1.2.1Diagnose tension‑type headache, migraine or cluster headache according to the headache features in table 1. Chronic migraine and chronic tension‑type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.

• Episodic tension-type headaches occur on fewer than 15 days per month. Chronic tension-type headaches occur on 15 or more days per month for more than 3 months.
• Episodic migraines (with or without aura) occur on fewer than 15 days per month. Chronic migraines (with or without aura) occur on 15 or more days per month for more than 3 months.
• Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month. Chronic cluster headaches occur from once every other day to 8 times a day with a continuous pain-free period of less than 1 month in a 12-month period.

Migraine with aura

1.2.2Suspect aura in people who present with or without headache and with neurological symptoms that:are fully reversible and develop gradually, either alone or in succession, over at least 5 minutes and last for 5 to 60 minutes. [2012]

1.2.3Diagnose migraine with aura in people who present with or without headache and with one or more of the following typical aura symptoms that meet the criteria in recommendation 1.2.2:visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)speech disturbance. [2012]

1.2.4Consider further investigations and/or referral for people who present with or without migraine headache and with any of the following atypical aura symptoms that meet the criteria in recommendation 1.2.2:motor weakness or double vision or visual symptoms affecting only one eye or poor balance or decreased level of consciousness. [2012]

Menstrual‑related migraine

1.2.5Suspect menstrual‑related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles. [2012]

1.2.6Diagnose menstrual‑related migraine using a headache diary (see recommendation 1.1.4) for at least 2 menstrual cycles. [2012]

Medication overuse headache

1.2.7Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more. [2012]

1.3 Management

All headache disorders

1.3.1Consider using a headache diary:to record the frequency, duration and severity of headaches,to monitor the effectiveness of headache interventions ,as a basis for discussion with the person about their headache disorder and its impact. [2012]

1.3.2Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the features listed in recommendation 1.1.1. [2012]

1.3.3Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. [2012]

Information and support for people with headache disorders

1.3.4Include the following in discussions with the person with a headache disorder: a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded and the options for management and recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers. [2012]

1.3.5Give the person written and oral information about headache disorders, including information about support organisations. [2012]

1.3.6Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder. [2012]

Tension‑type headache

Acute treatment

1.3.7Consider aspirin, paracetamol or an NSAID for the acute treatment of tension‑type headache, taking into account the person's preference, comorbidities and risk of adverse events.Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s. [2012]

1.3.8Do not offer opioids for the acute treatment of tension‑type headache. [2012]

Prophylactic treatment

1.3.9Consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks for the prophylactic treatment of chronic tension‑type headache. [2012]

Migraine with or without aura

Acute treatment

1.3.10 Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12 to 17 years consider a nasal triptan in preference to an oral triptan. [2012]In November 2015, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.

1.3.11For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. [2012]In November 2015, this was an off-label use of triptans in under 18s.

1.3.12When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans. [2012]In November 2015, this was an off-label use of triptans in under 18s.

1.3.13Consider an anti‑emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting. [2012]

1.3.14Do not offer ergots or opioids for the acute treatment of migraine. [2012]

1.3.15For people in whom oral preparations (or nasal preparations in young people aged 12 to 17 years) for the acute treatment of migraine are ineffective or not tolerated:offer a non‑oral preparation of metoclopramide or prochlorperazine and consider adding a non‑oral NSAID or triptan if these have not been tried. [2012]In November 2015, only a buccal preparation of prochlorperazine was licensed for this indication (prochlorperazine was licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off‑label use of metoclopramide in children and young people.

Prophylactic treatment

1.3.16Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the person's preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life. [2012]

1.3.17For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion: the potential benefit in reducing migraine recurrence and severity the risk of fetal malformations with topiramate, the risk of reduced effectiveness of hormonal contraceptives with topiramate,the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method).

People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.

1.3.18Consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events.

1.3.19Do not offer gabapentin for the prophylactic treatment of migraine. [2015]

1.3.20If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks according to the person's preference, comorbidities and risk of adverse events. [2012, amended 2015]

1.3.21For people who are already having treatment with another form of prophylaxis and whose migraine is well controlled, continue the current treatment as required. [2012, amended 2015]

1.3.22Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment. [2012]

1.3.23Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people. [2012]

Combined hormonal contraceptive use by women and girls with migraine

1.3.24Do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura. [2012]

Menstrual-related migraine

1.3.25For women and girls with predictable menstrual‑related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected. [2012]

Treatment of migraine during pregnancy

1.3.26Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptan or an NSAID after discussing the woman's need for treatment and the risks associated with the use of each medication during pregnancy. [2012]

1.3.27Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy. [2012]

Cluster headache

Acute treatment

1.3.28Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist. [2012]

1.3.29Offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache. [2012]

1.3.30When using oxygen for the acute treatment of cluster headache:use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and arrange provision of home and ambulatory oxygen. [2012]

1.3.31When using a subcutaneous or nasal triptan, ensure the person is offered an adequate supply of triptans calculated according to their history of cluster bouts, based on the manufacturer's maximum daily dose. [2012]In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication.

1.3.32Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache. [2012]

Prophylactic treatment

1.3.33Consider verapamil for prophylactic treatment during a bout of cluster headache. If unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring. [2012]

1.3.34Seek specialist advice for cluster headache that does not respond to verapamil. [2012]

In November 2015, this was an off-label use of verapamil. See NICE's information on prescribing medicines.

1.3.35Seek specialist advice if treatment for cluster headache is needed during pregnancy. [2012]

Medication overuse headache

1.3.36Explain to people with medication overuse headache that it is treated by withdrawing overused medication. [2012]

1.3.37Advise people to stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually. [2012]

1.3.38Advise people that headache symptoms are likely to get worse in the short term before they improve and that there may be associated withdrawal symptoms, and provide them with close follow‑up and support according to their needs. [2012]

1.3.39Consider prophylactic treatment for the underlying primary headache disorder in addition to withdrawal of overused medication for people with medication overuse headache. [2012]

1.3.40Do not routinely offer inpatient withdrawal for medication overuse headache. [2012]

1.3.41Consider specialist referral and/or inpatient withdrawal of overused medication for people who are using strong opioids, or have relevant comorbidities, or in whom previous repeated attempts at withdrawal of overused medication have been unsuccessful. [2012]

1.3.42Review the diagnosis of medication overuse headache and further management 4 to 8 weeks after the start of withdrawal of overused medication. [2012]