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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 with migraine (with or without aura)
Person with migraine (with or without aura)
Acute treatment
Acute treatment
Acute treatment
Offer combination therapy with an oral triptanAt the time this pathway was created (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. 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. 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 people aged 12–17 years consider a nasal triptan in preference to an oral triptan.
For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirinBecause of an association with Reye's syndrome, preparations containing aspirin should not be offered to people aged under 16 years. (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events.
When prescribing a triptan, start with the one with the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.
Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.
Do not offer ergots or opioids for the acute treatment of migraine.
For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated:
- offer a non-oral preparation of metoclopramide or prochlorperazineAt the time this pathway was created (September 2012) prochlorperazine (except a buccal preparation) did not have a UK marketing authorisation for this indication but was licensed for the relief of nausea and vomiting. 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. and
- consider adding a non-oral NSAID or triptan if these have not been tried.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeProphylactic treatment
Prophylactic treatment
Prophylactic treatment
Discuss 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.
Offer topiramateAt the time this pathway was created (September 2012) topiramate 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 propranolol for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.
If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentinAt the time this pathway was created (September 2012) gabapentin 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. (up to 1200 mg per day) according to the person's preference, comorbidities and risk of adverse events.
For people who are already having treatment with another form of prophylaxis such as amitriptylineAt the time this pathway was created (September 2012) amitriptyline 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. , and whose migraine is well controlled, continue the current treatment as required.
Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.
Advise people with migraine that riboflavin (400 mgAt the time this pathway was created (September 2012) riboflavin did not have a UK marketing authorisation for this indication but is available as a food supplement. When advising this option, the prescriber should take relevant professional guidance into account. 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. once a day) may be effective in reducing migraine frequency and intensity for some people.
Botulinum toxin type A
Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine):
- that has not responded to at least three prior pharmacological prophylaxis therapies and
- whose condition is appropriately managed for medication overuse.
Treatment with botulinum toxin type A that is recommended according to these criteria should be stopped in people whose condition:
- is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after two treatment cycles) or
- has changed to episodic migraine (defined as fewer than 15 headache days per month) for three consecutive months.
People currently receiving botulinum toxin type A that is not recommended according to the criteria above should have the option to continue treatment until they and their clinician consider it appropriate to stop.
These recommendations are from Botulinum toxin type A for the prevention of headaches in adults with chronic migraine (NICE technology appraisal guidance 260).
NICE has produced information for the public explaining the guidance on botulinum toxin type A to prevent chronic migraine headaches.
NICE interventional procedures guidance
NICE has published interventional procedures guidance on the following procedures:
- Percutaneous closure of patent foramen ovale for recurrent migraine (NICE interventional procedure guidance 370).
- Occipital nerve stimulation for intractable chronic migraine (NICE interventional procedure guidance 452).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSpecial considerations for women and girls with migraine
Special considerations for women and girls with migraine
Special considerations for women and girls with migraine
Menstrual-related migraine
For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptanAt the time this pathway was created (September 2012) frovatriptan 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. (2.5 mg twice a day) or zolmitriptanAt the time this pathway was created (September 2012) zolmitriptan 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. (2.5 mg twice or three times a day) on the days migraine is expected.
Combined hormonal contraceptive use
Do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura.
Treatment of migraine during pregnancy
Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptanAt the time this pathway was created (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. 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 an NSAID after discussing the woman's need for treatment and the risks associated with the use of each medication during pregnancy.
Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.
Source guidance
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Pathway created: September 2012 Last updated: May 2013
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