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Headaches
Short Text
Introduction
This pathway covers the diagnosis and management of the most common primary headache disorders in young people (aged 12 years and older) and adults.
Headaches are one of the most common neurological problems presented to GPs and neurologists. They are painful and debilitating for individuals, an important cause of absence from work or school and a substantial burden on society.
Healthcare professionals can find the diagnosis of headache difficult, and both people with headache and their healthcare professionals can be concerned about possible underlying causes. Improved recognition of primary headaches will help the generalist clinician to manage headaches more effectively, allow better targeting of treatment and potentially improve quality of life and reduce unnecessary investigations for people with headache.
Source guidance
The NICE guidance that was used to create the pathway.
Headaches. NICE clinical guideline 150 (2012)
Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. NICE technology appraisal guidance 260 (2012)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
Education and learning
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
Service improvement and audit
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
7 May 2013 Minor maintenance updates.
23 April 2013 Amendment to footnote 3 on prochlorperazine in the acute treatment of migraine (with or without aura). 'Occipital nerve stimulation for intractable chronic migraine' (NICE interventional procedure guidance 452) added to management of migraine (with or without aura).
21 September 2012 Minor maintenance updates.
Supporting information
Diagnosis table for tension-type headache, migraine and cluster headache
Headache feature | Tension-type headache | Migraine (with or without aura) | Cluster headache | ||||
|---|---|---|---|---|---|---|---|
Pain location1 | Bilateral | Unilateral or bilateral | Unilateral (around the eye, above the eye and along the side of the head/face) | ||||
Pain quality | Pressing/tightening (non-pulsating) | Pulsing (throbbing or banging in young people aged 12–17 years) | Variable (can be sharp, boring, burning, throbbing or tightening) | ||||
Pain intensity | Mild or moderate | Moderate or severe | Severe or very severe | ||||
Effect on activities | Not aggravated by routine activities of daily living | Aggravated by, or causes avoidance of, routine activities of daily living | Restlessness or agitation | ||||
Other symptoms | None | Unusual sensitivity to light and/or sound or nausea and/or vomiting Aura2 Aura symptoms can occur with or without headache and:
Typical aura symptoms include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory symptoms such as numbness and/or pins and needles; and/or speech disturbance. | On the same side as the headache:
| ||||
Duration of headache | 30 minutes–continuous |
| 15–180 minutes | ||||
Frequency of headache | Less than 15 days per month | 15 days per month or more for more than 3 months | Less than 15 days per month | 15 days per month or more for more than 3 months | 1 every other day to 8 per day3, with remission4 more than 1 month | 1 every other day to 8 per day3, with a continuous remission4 less than 1 month in a 12-month period | |
Diagnosis | Episodic tension-type headache | Chronic tension-type headache5 | Episodic migraine (with or without aura) | Chronic migraine (with or without aura)6 | Episodic cluster headache | Chronic cluster headache | |
1 Headache pain can be felt in the head, face or neck. 2 For further information on diagnosis of migraine with aura see tension-type headache, migraine (with or without aura) and cluster headache in this pathway. 3 The frequency of recurrent headaches during a cluster headache bout. 4 The pain-free period between cluster headache bouts. 5 Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine. 6 NICE has developed technology appraisal guidance on Botulinum toxin type A for the prevention of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine). See prophylactic treatment in this pathway. | |||||||
Glossary
An uncommon eye condition that results from blockage of the drainage of fluid from the eye. Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi-dilated pupil compared with the presence of a constricted pupil in cluster headache.
The duration over which recurrent cluster headaches occur, usually lasting weeks or months. Headaches occur from once every other day to 8 times per day
Central nervous system
Also known as temporal arteritis, giant cell arteritis is characterised by the inflammation of the walls of medium and large arteries. Branches of the carotid artery and the ophthalmic artery are preferentially involved, giving rise to symptoms of headache, visual disturbances and jaw claudication
Non-steroidal anti-inflammatory drug
A diagnosis based on the typical clinical picture that does not require any further investigations to exclude alternative explanations for a patient's symptoms
People aged 12 to 17 years
Assessment
Assessment
Assessment
People presenting with headache
Evaluate people who present with headache and any of these 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.
For NICE guidance on referral for suspected brain or CNS tumours see Referral for suspected cancer; update under development (publication date to be confirmed).
Further assessment for people presenting with new-onset headache
Consider 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.
Headache diaries
Consider using a headache diary to aid the diagnosis of primary headaches.
If 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.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeManagement of headaches
View the 'Management of headaches' pathPaths in this pathway
Pathway created: September 2012 Last updated: May 2013
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