# data[].attributes.body
Most patients presenting to health services with headaches have primary headache (up to 95% presenting to primary care and over 50% presenting to A&E).

The most common primary headache is migraine, making up the majority of these patients.

# data[].attributes.body
Site

Onset

Character

Radiation

Associated Symptoms

Timing

Exacerbated by...

Severity

# data[].attributes.body
Evaluate people who present with headache and any of the following feature and refer/investigate :

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

Refer/investigate 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

# data[].attributes.body
Site: Bilateral

Duration: 30 minutes to continuous

Character: Pressing/tightening (non-pulsating)

Timing: Episodic = <15 days per month, Chronic = ≥15 days per month for more than 3 months

Exacerbated by: Not aggravated by routine activities of daily living

Severity: Mild or moderate

# data[].attributes.body
Site: Unilateral or Bilateral

Duration: 4-72 hours in adults, 1-72 hours in young people aged 12-17 years

Character: Pulsating (throbbing or banging in young people aged 12-17 years)

Associated symptoms: Aura (symptoms of aura 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

Timing: Episodic = <15 days per month, Chronic = >15 days per month for more than 3 months

Exacerbated by: Aggravated by, or causes avoidance of, routine activities of daily living.

Such as unusual sensitivity to light and/or sound or nausea and/or vomiting

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

Severity: Moderate or Severe

# data[].attributes.body
Site: Unilateral (around the eye, above the eye, and along the side of the head/face)

Duration: 15-180 minutes

Character: Variable (can be sharp, boring, burning, throbbing or tightening)

Associated symptoms: Restlessness or agitation. 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

Timing: Episodic = one every day to eight per day, with remission >1 month, Chronic = one every other day to eight per day, with a continuous remission <1 month in a 12 month period

Severity: Severe or very severe

# data[].attributes.attachment_link.title
Cluster Headaches - Overview | OUCH(UK) - The Cluster Headache Charity

# data[].attributes.attachment_link.description
Cluster headaches (CH) are part of a group of ‘primary’ headaches named Trigeminal Autonomic Cephalgias (TACs). There are three other types of TAC, namely Paroxysmal Hermicrania (PH) SUNCT Syndrome [Short lasting unilateral headache with conjunctival injection and tearing] and Hemicrania Continua

# data[].attributes.body
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

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

# data[].attributes.body
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

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

# data[].attributes.body
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

# data[].attributes.headline
Acute Management of Migraine with or without Aura

# data[].attributes.subject
Acute Management of Migraine with or without Aura

# data[].attributes.body
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 medicine

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.

# data[].attributes.headline
Prophylactic Management of Migraine with or without Aura

# data[].attributes.subject
Prophylactic Management of Migraine with or without Aura

# data[].attributes.body
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

# data[].attributes.body
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

# data[].attributes.headline
Prophylactic Treatment of Cluster Headache

# data[].attributes.subject
Prophylactic Treatment of Cluster Headache

# data[].attributes.body
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

# data[].attributes.body
British Association for the Study of Headache (BASH)

NICE CKS Cluster Headache

International Headache Society

NICE Headache in over 12s: diagnosis and management

NICE Migraine in adults

# data[].attributes.body
NHS Scotland: National Headache Pathway

See pathway for further details on flags

# data[].attributes.body
The Migraine Trust Website

# data[].attributes.attachment_link.title
National Migraine Centre - Specialist treatment of migraine & headaches

# data[].attributes.attachment_link.description
Specialist treatment of migraine & headaches