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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
Person diagnosed with headache disorder
Person diagnosed with headache disorder
Information and support for people with headache disorders
Information and support for people with headache disorders
Information and support for people with headache disorders
Include 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.
Give the person written and oral information about headache disorders, including information about support organisations.
Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder.
NICE has written information for the public explaining the guidance on headaches.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAll headache disorders
All headache disorders
All headache disorders
Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.
Consider 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.
Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the following features.
- 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).
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.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeFailed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleTension-type headache
Tension-type headache
Tension-type headache
Acute treatment
Consider aspirinBecause of an association with Reye's syndrome, preparations containing aspirin should not be offered to people aged under 16 years., paracetamol or an NSAID for the acute treatment of tension-type headache, taking into account the person's preference, comorbidities and risks of adverse events.
Do not offer opioids for the acute treatment of tension-type headache.
Prophylactic treatment
Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeMigraine (with or without aura)
View the 'Management of migraine (with or without aura)' pathCluster headache
Cluster headache
Cluster headache
Acute treatment
Discuss 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.
Offer oxygen and/or a subcutaneousAt the time this pathway was created (September 2012) subcutaneous triptans 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. See the General Medical Council's Good practice in prescribing medicines − guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. or nasal tripanAt the time this pathway was created (September 2012) nasal triptans did not have a UK marketing authorisation for this indication. 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. See the General Medical Council's Good practice in prescribing medicines − guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. for the acute treatment of cluster headache.
When 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.
When 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.
Do not offer paracetamol, an NSAID, opioids, ergots or oral triptans for the acute treatment of cluster headache.
Prophylactic treatment
Consider verapamilAt the time this pathway was created (September 2012) verapamil did not have a UK marketing authorisation for this indication. 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. See the General Medical Council's Good practice in prescribing medicines − guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 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.
Seek specialist advice if treatment for cluster headache is needed during pregnancy.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeMedication overuse headache
Medication overuse headache
Medication overuse headache
Explain to people with medication overuse headache that it is treated by withdrawing overused medication.
Advise people to stop taking all overused headache medications for at least 1 month and to stop abruptly rather than gradually.
Advise 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.
Consider prophylactic treatment for the underlying primary headache disorder in addition to withdrawal of overused medication for people with medication overuse headache.
Do not routinely offer inpatient withdrawal for medication overuse headache.
Consider 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.
Review the diagnosis of medication overuse headache and further management 4–8 weeks after the start of withdrawal of overused medication.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: September 2012 Last updated: May 2013
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