Headaches in Over 12s: Diagnosis and Management

This Guidelines summary covers advice on the diagnosis and management of tension-type headache, migraine (including migraine with aura and menstrual-related migraine), cluster headache, and medication overuse headache in young people (aged 12 years and older) and adults. It aims to improve the recognition and management of headaches, with more targeted treatment to improve the quality of life for people with headaches, and to reduce unnecessary investigations. 

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

MHRA advice on antiepileptic drugs in pregnancy: In May 2021, NICE amended its recommendation on topiramate for migraine prophylaxis to include discussion of the potential benefits and risks, and the importance of effective contraception for women and girls of childbearing potential when taking topiramate.

Assessment

• Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral:
  • 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 information on referral for suspected tumours of the brain or central nervous system, see the NICE guideline on suspected cancer.
• 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.
• Consider using a headache diary to aid the diagnosis of primary headaches.
• 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.

Diagnosis

Table 1: Headache Features According to Headache Type

Tension-type Headache, Migraine (With or Without Aura), and Cluster Headache

• Diagnose tension-type headache, migraine, or cluster headache according to the headache features in Table 1.

Migraine With Aura

• 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.
• 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 (see previous recommendation):
  • 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.
• 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 (see migraine with aura):
  • motor weakness or
  • double vision or
  • visual symptoms affecting only one eye or
  • poor balance or
  • decreased level of consciousness.

Menstrual-related Migraine

• 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.
• Diagnose menstrual-related migraine using a headache diary for at least 2 menstrual cycles.

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 non-steroidal anti-inflammatory drug (NSAID), either alone or in any combination, on 15 days per month or more.

Management

All Headache Disorders

• 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 features (see the Assessment section).
• 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

• 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.

Tension-type Headache

Acute Treatment

• Consider aspirin, 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.
  
  Because of the association with Reye's syndrome, preparation containing aspirin should not be offered to under 16s.
   
• 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.

Migraine With or Without Aura

Acute Treatment

• Offer combination therapy with an oral triptan 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 young people aged 12–17 years consider a nasal triptan in preference to an oral triptan.
  
  In November 2015, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. See NICE's information on prescribing medicines.
   
• For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg), or paracetamol for the acute treatment of migraine, taking into account the person’s preference, comorbidities, and risk of adverse events.
  
  In November 2015, this was an off-label use of triptans in under 18s. See NICE's information on prescribing medicines. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s.
   
• When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.
  
  In November 2015, this was an off-label use of triptans in under 18s. See NICE's information on prescribing medicines.
   
• 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:
  • consider a non-oral preparation of metoclopramide or prochlorperazine and
  • if non-oral metoclopramide or prochlorperazine is used, consider adding a non-oral NSAID or triptan if they have not been tried.Note the special warnings and precautions for use in the summaries of product characteristics for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
    
    In November 2015, only a buccal preparation of prochlorperazine was licensed for this indication (prochlorperazine was licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people. See NICE's information on prescribing medicines.

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.
• For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:
  • the potential benefit in reducing migraine recurrence and severity
  • the risk of fetal malformations with topiramate
  • the risk of reduced effectiveness of hormonal contraceptives with topiramate
  • the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method).
    
    Follow the MHRA safety advice on antiepileptic drugs in pregnancy.
    
    In November 2015, this was an off-label use of topiramate in children and young people. See NICE's information on prescribing medicines.
    
    People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.
• Consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities, and risk of adverse events.
  
  In November 2015, this was an off-label use of amitriptyline. See NICE's information on prescribing medicines.
• Do not offer gabapentin for the prophylactic treatment of migraine.
• If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks according to the person's preference, comorbidities, and risk of adverse events.
• For people who are already having treatment with another form of prophylaxis 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 mg once a day) may be effective in reducing migraine frequency and intensity for some people.
  
  In November 2015, this was an off-label use of riboflavin, but this is available as a food supplement.

Combined Hormonal Contraceptive Use by Women and Girls With Migraine

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

Menstrual-related Migraine

• For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected.
  
  In November 2015, this was an off-label use of frovatriptan and zolmitriptan. See NICE's information on prescribing medicines.

Treatment of Migraine During Pregnancy

• Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptan or an NSAID after discussing the woman’s need for treatment and the risks associated with the use of each medication during pregnancy.
  
  In November 2015, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. See NICE's information on prescribing medicines.
   
• Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.

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 subcutaneous or nasal triptan for the acute treatment of cluster headache.
  
  In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.
   
• 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.
  
  In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.
   
• Do not offer paracetamol, NSAIDs, opioids, ergots, or oral triptans for the acute treatment of cluster headache.

Prophylactic Treatment

• Consider verapamil 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.
  
  In November 2015, this was an off-label use of verapamil. See NICE's information on prescribing medicines.
   
• Seek specialist advice for cluster headache that does not respond to verapamil.
  
  In November 2015, this was an off-label use of verapamil. See NICE's information on prescribing medicines.
   
• Seek specialist advice if treatment for cluster headache is needed during pregnancy.

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 acute 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.