Key priorities for implementation

The following recommendations were identified as priorities for implementation in 2012. In 2015, the evidence was reviewed for the key priority recommendation on prophylactic treatment, but no change was made to the recommended action. No changes were made to the other key priority recommendations.

Tension‑type headache, migraine and cluster headache

  • Diagnose tension‑type headache, migraine or cluster headache according to the headache features in the table. [2012]

Medication overuse headache

  • 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 any combination, on 15 days per month or more. [2012]

Management

All headache disorders

  • Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. [2012]

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. [2012]

Migraine with or without aura

Acute treatment
  • Offer combination therapy with an oral triptan[1]and an NSAID, or an oral triptan[1] 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[1]. [2012]

  • 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[2] or prochlorperazine[3]and

    • consider adding a non‑oral NSAID or triptan[1] if these have not been tried. [2012]

Prophylactic treatment
  • Offer topiramate or propranolol[4] 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 needed. [2015]

Cluster headache

Acute treatment
  • Offer oxygen and/or a subcutaneous[5] or nasal triptan[6] for the acute treatment of cluster headache. [2012]

  • 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. [2012]

  • When using a subcutaneous[5] or nasal triptan[6], 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. [2012]



[1] At the time of publication (November 2015), triptans (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. Nasal sumatriptan did not have a UK marketing authorisation for this indication in people aged under 12 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.

[2] At the time of publication (November 2015), metoclopramide did not have a UK marketing authorisation for use in children and young people for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[3] At the time of publication (November 2015), 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.

[4] At the time of publication (November 2015), topiramate did not have a UK marketing authorisation for use in children and young people for this indication. Propranolol did not have a UK marketing authorisation for use in children under 12 years for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[5] At the time of publication (November 2015), 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.

[6] At the time of publication (November 2015), 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.

  • National Institute for Health and Care Excellence (NICE)