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Headaches HAI

About

What is covered

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.

Updates

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.
NICE has also written a document for patients and the public explaining its quality standard for headaches in young people and adults

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

4 February 2014 Minor maintenance updates.
21 January 2014 Minor maintenance updates.
27 August 2013 Headaches in young people and adults quality standard (QS42) added to 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.

Short Text

Diagnosis and management of headaches in young people and adults

What is covered

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.

Sources

The NICE guidance that was used to create the pathway.
Headaches. NICE clinical guideline 150 (2012)
Transcranial magnetic stimulation for treating and preventing migraine. NICE interventional procedure guidance 477 (2014)
Occipital nerve stimulation for intractable chronic migraine. NICE interventional procedure guidance 452 (2013)
Percutaneous closure of patent foramen ovale for recurrent migraine. NICE interventional procedure guidance 370 (2010)

Quality standards

Headaches in young people and adults quality standard

These quality statements are taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

Quality statements

Classification of headache type

This quality statement is taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

Quality statement

People diagnosed with a primary headache disorder have their headache type classified as part of the diagnosis.

Rationale

Classifying headache type according to the features of the headache will allow people with a primary headache disorder to receive appropriate treatment and prevention for their headaches. It is recognised that some people will have more than one headache disorder and therefore have more than one classification. Accurate classification and treatment has the potential to reduce referrals for unnecessary investigations and contribute to improved quality of life for people with a headache disorder.

Quality measure

Structure
Evidence of local arrangements to ensure that people diagnosed with a primary headache disorder have their headache type classified as part of the diagnosis.
Data source: Local data collection.
Process
Proportion of people diagnosed with a primary headache disorder who have their headache type classified as part of the diagnosis.
Numerator – the number of people in the denominator who have their headache type classified as part of the diagnosis.
Denominator – the number of people diagnosed with a primary headache disorder.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for people diagnosed with a primary headache disorder to have their headache type classified as part of the diagnosis.
Healthcare practitioners ensure that people diagnosed with a primary headache disorder have their headache type classified as part of the diagnosis.
Commissioners ensure that they commission services that classify headache type for people diagnosed with a primary headache disorder as part of the diagnosis.

What the quality statement means for patients, service users and carers

People with a headache disorder with no known cause (sometimes called a primary headache disorder) have the type of their headache classified as part of their diagnosis. Common headache types include tension-type headache, migraine and cluster headache.

Source guidance

Headaches (NICE clinical guideline 150), recommendations 1.2.1 (key priority for implementation), 1.1.1 and 1.1.2.

Definitions of terms used in this quality statement

Primary headache disorders include tension-type headache, migraine and cluster headache as defined in the headache features table (see the diagnosis of tension-type headache, migraine and cluster headache table in NICE clinical guideline 150) and which have been diagnosed as a result of excluding other causes and taking a history.
Excluding other causes
NICE clinical guideline 150 lists the signs and symptoms of secondary headaches for which further investigations and/or referral may be considered as:
  • worsening headache with fever
  • sudden-onset headache reaching maximum intensity within 5 minutes
  • new-onset neurological defect
  • 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 (headaches that change with posture)
  • symptoms suggestive of giant cell arteritis
  • symptoms and signs of acute narrow-angle glaucoma
  • a substantial change in characteristics of their headache.
NICE clinical guideline 150 also states criteria for which further investigations and/or referral may be considered for people who present with new-onset headache. These are:
  • 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 (for example a migraine attack).

Equality and diversity considerations

The diagnosis of a primary headache disorder is usually based on subjective symptoms. Some people may need support to accurately describe their symptoms, including children and those with additional needs such as physical, sensory or learning disabilities and people who do not speak English. The support should be tailored to the person, and people presenting with a headache should have access to an interpreter or advocate if needed.

Preventing medication overuse headache

This quality statement is taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

Quality statement

People with a primary headache disorder are given information on the risk of medication overuse headache.

Rationale

Medication overuse is a cause of secondary headaches in people with a primary headache disorder. Providing information to people with a primary headache disorder about the risk of medication overuse may prevent these secondary headaches.

Quality measure

Structure
Evidence of local arrangements to ensure that people with a primary headache disorder are given information on the risk of medication overuse headache.
Data source: Local data collection.
Process
Proportion of people with a primary headache disorder who are given information on the risk of medication overuse headache.
Numerator – the number of people in the denominator who are given information on the risk of medication overuse headache.
Denominator – the number of people with a primary headache disorder.
Data source: Local data collection.
Outcome
Incidence of medication overuse headache.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for people diagnosed with a primary headache disorder to be given information on the risk of medication overuse headache.
Healthcare practitioners including pharmacists give people with a primary headache disorder information on the risk of medication overuse headache.
Commissioners ensure that they commission services that give people with a primary headache disorder information on the risk of medication overuse headache.

What the quality statement means for patients, service users and carers

People with a headache disorder with no known cause are given information about the risk of too much medication causing more headaches.

Source guidance

Headaches (NICE clinical guideline 150), recommendation 1.3.6.

Definitions of terms used in this quality statement

Primary headache disorders include tension-type headache, migraine and cluster headache.
Medication overuse headaches are headaches associated with taking too much medication. They most commonly occur in people taking medication for a primary headache disorder, especially for tension-type headaches and migraine.

Equality and diversity considerations

All information given about the risk of medication overuse headache should be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. People with a primary headache disorder should have access to an interpreter or advocate if needed.
It may be appropriate in some cases, particularly with young people, to provide information to parents and carers as well as the person with the headache disorder.

Imaging

This quality statement is taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

Quality statement

People with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.

Rationale

Referral for imaging solely for reassurance is most common in people diagnosed with tension-type headache and migraine. Therefore, the potential to reduce inappropriate referrals is greatest for these headache types. When healthcare professionals are confident about the diagnosis and classification of tension-type headache or migraine, imaging provides no more information and can lead to delays in diagnosis and treatment, and unnecessary anxiety for people.

Quality measure

Structure
Evidence of local arrangements to ensure that people with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.
Data source: Local data collection.
Process
Proportion of people with a tension-type headache or migraine who are referred for imaging.
Numerator – the number of people in the denominator referred for imaging.
Denominator – the number of people with tension-type headache or migraine.
Data source: Local data collection.
Outcome
Rate of positive findings of cause of headache on imaging.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place so that people with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.
Healthcare practitioners do not refer people for imaging if they have tension-type headache or migraine and no signs or symptoms of secondary headache.
Commissioners ensure that they commission services that do not refer people for imaging if they have tension-type headache or migraine and no signs or symptoms of secondary headache.

What the quality statement means for patients, service users and carers

People with tension-type headache or migraine are not referred for a brain scan if they do not have signs or symptoms of other conditions known to cause headaches.

Source guidance

Headaches (NICE clinical guideline 150), recommendations 1.3.3 (key priority for implementation), 1.1.1 and 1.1.2.

Definitions of terms used in this quality statement

Signs and symptoms of secondary headache are listed in NICE clinical guideline 150 as:
  • worsening headache with fever
  • sudden-onset headache reaching maximum intensity within 5 minutes
  • new-onset neurological defect
  • 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 (headaches that change with posture)
  • symptoms suggestive of giant cell arteritis
  • symptoms and signs of acute narrow-angle glaucoma
  • a substantial change in characteristics of their headache.
NICE clinical guideline 150 also states criteria for which further investigations and/or referral may be considered for people who present with new-onset headache. These are:
  • 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 (for example a migraine attack).
Imaging includes CT, MRI or MRI variants.

Equality and diversity considerations

Some people may be anxious about not being referred for imaging and may need reassurance. Reassurance should take into account the needs of the individual, particularly any cultural needs, physical, sensory or learning disabilities, and of people who do not speak or read English. People should have access to an interpreter or advocate if needed.

Combined treatment for migraine

This quality statement is taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

Quality statement

People with migraine are advised to take combination therapy with a triptan and either a non-steroidal anti-inflammatory drug (NSAID) or paracetamol.

Rationale

Correct treatment can relieve the symptoms of migraine and improve quality of life. Previously, people with migraine would have been treated with a stepped-care approach; however, evidence shows that combination therapy with a triptan and either an NSAID or paracetamol is the most effective first-line treatment for migraine.

Quality measure

Structure
Evidence of local arrangements to ensure that people with migraine are advised to take combination therapy with a triptan and either an NSAID or paracetamol.
Data source: Local data collection.
Process
Proportion of people with migraine who are advised to take combination therapy with a triptan and either an NSAID or paracetamol.
Numerator – the number of people in the denominator who are advised to take combination therapy with a triptan and either an NSAID or paracetamol.
Denominator – the number of people with migraine.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place for people with migraine to be advised to take combination therapy with a triptan and either an NSAID or paracetamol.
Healthcare practitioners advise people with migraine to take combination therapy with a triptan and either an NSAID or paracetamol.
Commissioners ensure that they commission services that advise people with migraine to take combination therapy with a triptan and either an NSAID or paracetamol.

What the quality statement means for patients, service users and carers

People with migraine are advised to take a type of drug called a triptan, to be taken with either a type of drug called a non-steroidal anti-inflammatory drug (or sometimes called an NSAID) or paracetamol.

Source guidance

Headaches (NICE clinical guideline 150), recommendation 1.3.10 (key priority for implementation).

Definitions of terms used in this quality statement

Use of triptans For adults an oral triptan should be offered as part of combination therapy. For young people aged 12–17 years a nasal triptan should be considered in preference to an oral triptan.
At the time of publication of the guideline (September 2012), triptans (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented.
NSAIDs, paracetamol and some triptans are available over the counter at pharmacies and therefore may not always require a prescription.

Equality and diversity considerations

To ensure treatment is effective it should take into account the person's age, preference, comorbidities and risk of adverse events.

Placeholder statement: Raising public and professional awareness

This placeholder statement is taken from the headaches in young people and adults quality standard. The quality standard defines clinical best practice for headaches in young people and adults and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no NICE or NICE-accredited source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be accredited or developed in this area, and this area may be addressed when the source guidance is updated.

Rationale

Raising public and professional awareness of primary headache disorders has the potential to improve the quality of life for young people and adults with a primary headache disorder. This disorder remains under-diagnosed because often people do not consult a healthcare professional to obtain an accurate diagnosis. In some cases this leads to self-medication, which may be inappropriate and can lead to medication overuse headache. Raising public and professional awareness of headaches could increase the number of people consulting healthcare professionals, leading to an increase in accurate diagnoses and appropriate treatment and prevention of headaches.

Effective interventions library

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.

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.
NICE has also written a document for patients and the public explaining its quality standard for headaches in young people and adults

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

4 February 2014 Minor maintenance updates.
21 January 2014 Minor maintenance updates.
27 August 2013 Headaches in young people and adults quality standard (QS42) added to 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:
  • are fully reversible
  • develop over at least 5 minutes
  • last 5−60 minutes.
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:
  • red and/or watery eye
  • nasal congestion and/or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil and/or drooping eyelid
Duration of headache
30 minutes–continuous
  • 4–72 hours in adults
  • 1–72 hours in young people aged 12–17 years
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

Paths in this pathway

Pathway created: September 2012 Last updated: February 2014

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