NICE Clinical guideline [CG150] updated: November 2015. Headaches in over 12s: diagnosis and management 

Primary Headaches

History

• Tension: Bilateral, mild, tightening/non-pulsating, no impact on ADL

• Migraine: Unilateral moderate pulsating/throbbing + aura + photophobia + N&V + Impact on ADL + 4h-72hr duration

• Cluster: Unilateral, eye, severe sharp/boring/burning + autonomic features + restless/agitation + 15min-180min

• Autonomic features: tearing, swollen/red eye, nasal discharge, , drooping eyelid, constricted pupil

• If acute headache: fever, neck stiffness, weakness and visual disturbance, rash.

• Household contacts with similar symptoms [consider possible carbon monoxide poisoning]

• Family History of headache disorders

Main Red Flags

• Triggered by Valsalva (coughing, sneezing, bending or exertion), lying down worsens (SOL or CSVT)

• Vomiting

• Neurological or cognitive deficit

• [Menstrual or MOH triggers]

Medication-overuse headache (MOH)

Secondary headache disorder attributed to frequent use of analgesics or migraine-specific medications (such as triptans)
Defined as headache occurring on at least 15d per month in an individual with pre-existing headache disorder and regular medication overuse (>10-15d/month)
Treatment: withdraw overused medication (stop abruptly rather than gradually)

Menstrual migraine or menstrually-related migraine

Migraines may exclusively occur at menstruation or with heightened frequency at menses.
Acute treatment: standard monotherapy/combination therapies
Preventive treatment (perimenstrual): Frovatriptan or Zolmitriptan (2.5 mg TDS) starting -2 to day+5 of menstruation

Pregnancy and breastfeeding

Risk-benefit decisions for paracetamol, triptans with preventive treatment options of propranolol and amitriptyline

Priorities (Agendas, ICE, PSO)

Triggers (such as stress, work etc.)
Psychological co-morbidity- including anxiety and depression
Sickness from work
Medication overuse headache

Red Flags

Abbreviations:
Space-Occupying Lesion SOL (for example malignancy, haematoma)
Giant Cell Arteritis GCA, Cerebral Sinus Venous Thrombosis CSVT, Benign Intracranial Hypertension BICH
Cerebrovascular event CVA- ischaemic or haemorrhagic

Non-infective
Sudden‑onset severe headache [Intracranial haemorrhage, CSVT, hypertensive encephalopathy, vertebral artery dissection]
New-onset headache age>50y [GCA, SOL]
Progressive or persistent headache [GCA, SOL, subdural haematoma]
Papilloedema [SOL, CSVT, BICH]
Neurological deficit or cognitive/personality change [CVA, SOL, malignancy, subacute/chronic subdural haematoma]
Dizziness, vertigo [CVA]
Atypical aura (>1hr or motor weakness) or new-onset Aura with COC [CVA]
Visual change [Acute closure glaucoma, GCA, TIA/CVA]
Vomiting [SOL, brain abscess, CO poisoning]
Valsalva (coughing, sneezing, bending, exertion [physical or sexual]) [SOL, CSVT]
Orthostatic [Headaches that worsen on lying down consider SOL or CSVT]

Head trauma within the past 3m [Extradura/subdural hematoma]

Infective
Fever, impaired consciousness, seizure, neck pain/stiffness or photophobia [Meningitis or encephalitis]

Screen for GCA : visual disturbances, jaw claudication, temple tenderness, proximal muscle weakness

Screen for acute Narrow-Angle Glaucoma: painful red eye, blurred vision, semi‑dilated pupil

Examination

Temperature. BP
Fundoscopy (identify any papilloedema)
Cranial and peripheral nervous system examination.
Extracranial structures such as the neck, and temporal arteries (age>50y)

Treatment

Tension‑type headache

Acute
Aspirin, paracetamol or an NSAID (no opioids)

Prophylactic
Amitriptyline (10-75mg nocte)
Acupuncture

Migraine with or without aura

Acute
Oral triptan/ NSAID/paracetamol
Oral triptan +/- NSAID
Oral triptan +/- paracetamol
And anti‑emetic e.g. metoclopromide

Prophylactic
Propranolol 80-240mg daily in divided doses
Amitriptyline 25-75mg nocte
Topiramate (teratogenic) 50-100mg od
Riboflavin, Magnesium, Coenzyme Q10
Anti-CGRP monoclonal antibodies

Cluster headache

Acute
High-flow 100% oxygen (non‑rebreathing mask); Arrange home oxygen
Sumatriptan, s.c or intranasal ONLY
Zolmitriptan intransal ONLY

NO paracetamol, NSAIDs, opioids, oral triptans

Prophylactic
Verapamil

Extra notes

1. Sumatriptan’s highest to lowest efficacy order by (NNT): 6mg subcutaneous > 20mg intranasal > 50-100mg oral

2. Most effective to least effective oral triptan by (NNT): Rizatriptan 10mg (3.1), Eletriptan 80mg (3.7), Zolmitriptan 5mg (4.8), Sumatriptan 100mg (4.7)

3. Any conditions which predispose to coronary artery disease (CHD) are a contraindication to triptans: IHD/MI, CVD, uncontrolled hypertension, PAD

4. Human monoclonal antibody that binds to calcitonin gene-related peptide (CGRP) receptor, inhibiting the function of CGRP, prevents migraine.
   Monthly subcutaneous injections, initiated by specialists, in patients who have at least 4 migraine days per month: Fremanezumab, Galcanezumab, Erenumab

5. Recommend neurology referral and neuroimaging for people with the first bout of cluster headache, in order to confirm the diagnosis.

6. Advising the person on the risk of medication overuse headache.

7. Identifying and managing any comorbidities such as depression, anxiety, and sleep apnoea.

8. Provision of written and oral patient information on headaches and support organizations.

9. Referral to a specialist if uncertain about diagnosis/management or first line measures in primary care fail.

Safety-netting and Follow-up

Change in severity, pattern or addition of new symptoms (aura, trigger by orthostatic/exertion, neurological deficit, cognitive dysfunction, change in personality, impaired level of consciousness)