Headaches: Diagnosis and management of headaches in young people and adults

NICE guidelines [CG150] Published date:

1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

All recommendations apply to adults and young people aged 12 years and over unless specifically stated otherwise in the recommendation.

1.1 Assessment

1.1.1 Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral[6]:

  • 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.

1.1.2 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.

1.1.3 Consider using a headache diary to aid the diagnosis of primary headaches.

1.1.4 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.

1.2 Diagnosis

Tension-type headache, migraine (with or without aura) and cluster headache

1.2.1 Diagnose tension-type headache, migraine or cluster headache according to the headache features in the table.

Table Diagnosis of 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)

Pulsating (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

Aura 2

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

< 15 days per month

≥ 15 days per month for more than 3 months

< 15 days per month

≥ 15 days per month for more than 3 months

1 every other day to 8 per day3, with remission4 > 1 month

1 every other day to 8 per day3, with a continuous remission4 <1 month in a 12-month period

Diagnosis

Episodic tension-type headache

Chronic tension-type headache 5

Episodic migraine (with or without aura)

Chronic migraine 6 (with or without aura)

Episodic cluster headache

Chronic cluster headache

1 Headache pain can be felt in the head, face or neck.

2 See recommendations 1.2.2, 1.2.3 and 1.2.4 for further information on diagnosis of migraine with aura.

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).

Migraine with aura

1.2.2 Suspect aura in people who present with or without headache and with neurological symptoms that:

  • are fully reversible and

  • develop gradually, either alone or in succession, over at least 5 minutes and

  • last for 5–60 minutes.

1.2.3 Diagnose migraine with aura in people who present with or without headache and with one or more of the following typical aura symptoms that meet the criteria in recommendation 1.2.2:

  • visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)

  • sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)

  • speech disturbance.

1.2.4 Consider further investigations and/or referral for people who present with or without migraine headache and with any of the following atypical aura symptoms that meet the criteria in recommendation 1.2.2:

  • motor weakness or

  • double vision or

  • visual symptoms affecting only one eye or

  • poor balance or

  • decreased level of consciousness.

Menstrual-related migraine

1.2.5 Suspect menstrual-related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles.

1.2.6 Diagnose menstrual-related migraine using a headache diary (see recommendation 1.1.4) for at least 2 menstrual cycles.

Medication overuse headache

1.2.7 Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

  • triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or

  • paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more.

1.3 Management

All headache disorders

1.3.1 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.

1.3.2 Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the features listed in recommendation 1.1.1.

1.3.3 Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.

Information and support for people with headache disorders

1.3.4 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.

1.3.5 Give the person written and oral information about headache disorders, including information about support organisations.

1.3.6 Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder.

Tension-type headache

Acute treatment

1.3.7 Consider aspirin[7], paracetamol or an NSAID for the acute treatment of tension-type headache, taking into account the person's preference, comorbidities and risk of adverse events.

1.3.8 Do not offer opioids for the acute treatment of tension-type headache.

Prophylactic treatment

1.3.9 Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.

Migraine with or without aura

Acute treatment

1.3.10 Offer combination therapy with an oral triptan[8]and an NSAID, or an oral triptan[8] and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan[8].

1.3.11 For people who prefer to take only one drug, consider monotherapy with an oral triptan[8], NSAID, aspirin[7] (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events.

1.3.12 When prescribing a triptan[8] start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.

1.3.13 Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.

1.3.14 Do not offer ergots or opioids for the acute treatment of migraine.

1.3.15 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 prochlorperazine[9]and

  • consider adding a non-oral NSAID or triptan[8] if these have not been tried.

Prophylactic treatment

1.3.16 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.

1.3.17 Offer topiramate[10] 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.

1.3.18 If both topiramate[10] and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin[11] (up to 1200 mg per day) according to the person's preference, comorbidities and risk of adverse events.

1.3.19 For people who are already having treatment with another form of prophylaxis such as amitriptyline[12], and whose migraine is well controlled, continue the current treatment as required.

1.3.20 Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.

1.3.21 Advise people with migraine that riboflavin (400 mg[13] once a day) may be effective in reducing migraine frequency and intensity for some people.

Combined hormonal contraceptive use by women and girls with migraine

1.3.22 Do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura.

Menstrual-related migraine

1.3.23 For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan[14] (2.5 mg twice a day) or zolmitriptan[15] (2.5 mg twice or three times a day) on the days migraine is expected.

Treatment of migraine during pregnancy

1.3.24 Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptan[8] or an NSAID after discussing the woman's need for treatment and the risks associated with the use of each medication during pregnancy.

1.3.25 Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.

Cluster headache

Acute treatment

1.3.26 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.

1.3.27 Offer oxygen and/or a subcutaneous[16] or nasal triptan[17] for the acute treatment of cluster headache.

1.3.28 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.

1.3.29 When using a subcutaneous[16] or nasal triptan[17], 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.

1.3.30 Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache.

Prophylactic treatment

1.3.31 Consider verapamil[18]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.

1.3.32 Seek specialist advice for cluster headache that does not respond to verapamil[13].

1.3.33 Seek specialist advice if treatment for cluster headache is needed during pregnancy.

Medication overuse headache

1.3.34 Explain to people with medication overuse headache that it is treated by withdrawing overused medication.

1.3.35 Advise people to stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually.

1.3.36 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.

1.3.37 Consider prophylactic treatment for the underlying primary headache disorder in addition to withdrawal of overused medication for people with medication overuse headache.

1.3.38 Do not routinely offer inpatient withdrawal for medication overuse headache.

1.3.39 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.

1.3.40 Review the diagnosis of medication overuse headache and further management 4–8 weeks after the start of withdrawal of overused medication.



[6] For information on referral for suspected tumours of the brain or central nervous system see Referral guidelines for suspected cancer (NICE clinical guideline 27); update under development (publication date to be confirmed).

[7] Because of an association with Reye's syndrome, preparations containing aspirin should not be offered to people aged under 16 years.

[8] At the time of publication (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.

[9] At the time of publication (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.

[10] At the time of publication (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.

[11] At the time of publication (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.

[12] At the time of publication (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.

[13] At the time of publication (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.

[14] At the time of publication (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.

[15] At the time of publication (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.

[16] At the time of publication (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.

[17] At the time of publication (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.

[18] At the time of publication (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.

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