Dr Andrew Dowson explains how current guidelines on headache can help healthcare professionals to diagnose and treat patients suffering from this common condition

Headache is a common condition, with over 90% of the population experiencing a headache in their life. It is estimated that 11% of men and 22% of women have a headache at any one time.1 Classification of the primary chronic headaches is as shown in Table 1. The most frequently reported headaches are the benign primary headaches, which include:3

  • episodic tension-type headache (TTH)
  • episodic migraine
  • chronic daily headache (CDH, now categorised primarily as chronic migraine and chronic TTH, together with some rarer headaches). Chronic daily headache comprises daily or near-daily headaches that last for more than 4 hours on average, and is often linked to medication overuse (frequently codeine).4 It usually arises from a primary, episodic headache disorder (migraine or TTH).5

Table 1: Classification of primary chronic headaches in the International Headache Society (IHS) criteria2,3

Headache subtype Frequency Presentation
Chronic migraine

?15 days/month for >3 months

Primary headache is migraine

May present with migraine or TTH-like features


?15 days/month for >3 months

Primary headache is episodic TTH

Presents typically with TTH-like features

Medication overuse headache

>15 days/month

Chronic migraine, CTTH, or mixed migraine and TTH-like features

Overuse (?10 days/month for ?3 months) of ergots, triptans, opioids, combination headache medicines, or analgesics (?15 days/month)

Primary stabbing headache

Once a day to several times daily

Stabs of pain in the head, each lasting a few seconds

Hypnic headache

>15 days/month

Develops during sleep, awakens patient and lasts ?15 minutes after waking

Usually affects patients aged >50 years

Hemicrania continua

Daily and continuous

Unilateral, moderate intensity, with exacerbations of severe pain

Other symptoms: conjunctival injection/lacrimation, nasal congestion/rhinorrhoea, ptosis/miosis

Responds to indomethacin

New daily persistent headache

Daily and unremitting from within 3 days of onset

Presents typically with TTH-like symptoms

Cluster headache

Once every 2 days, to eight times/day

Severe unilateral, periorbital pain lasting 15–180 min

Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema

Restlessness and agitation

Male predominance

Chronic paroxysmal hemicrania

Several times daily for >1 year

Duration 2–30 minutes

Symptoms similar to cluster headache

Female predominance

Responds to indomethacin



Duration 5–240 seconds

Symptoms similar to cluster headache

TTH=tension-type headache; CTTH=chronic tension-type headache; SUNCT=short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing


Episodic TTH, episodic migraine, and CDH are all more common in women than in men: TTH affects 86% of women and 63% of men;6 migraine affects 18% and 8% of women and men, respectively;7 and CDH affects 9% and 1%, respectively.2 Other headache subtypes are relatively uncommon, affecting less than 1% of the population,1 including the so-called sinister (secondary) headaches, which are rarely seen (although they are often worried about) in primary care.

Despite its common occurrence, headache remains frequently unrecognised, undiagnosed, and poorly treated in primary care, and is a major public health problem. Many patients do not consult a GP for headache, and rely on over-the-counter medicines from shops or pharmacists.7 Fortunately, evidence-based guidelines for headache management in primary care have been published over the past few years, which encompass both migraine8 and chronic headaches,2 and target GPs,2,7 practice nurses,9 and community pharmacists.1 These guidelines were all prepared by a multidisciplinary group under the auspices of the Migraine in Primary Care Advisors (MIPCA), the leading UK charity promoting headache management in primary care. The majority of these guidelines can be accessed on the MIPCA website (www.mipca.org.uk) and guideline summaries are also available in the Guidelines handbook.

This article describes the main features of the headache guidelines, and outlines recent initiatives to help with their implementation in primary care.

Principles of care

The MIPCA guidelines for GPs on migraine8 and chronic headache2 are based on seven principles of care that are generic in scope (see Table 2). These principles can be applied for all headache subtypes, with customisation of the medicines prescribed.

Table 2: Seven principles of care for headache management

  1. Screening—a headache history should be used to obtain information needed during the initial screening procedures. This should include details of the patient’s symptoms, any associated disability, and any medicine/s used.
  2. Patient education and commitment—the patient should be provided with information (e.g. verbal advice, leaflets, website addresses, and patient support organisations) and their commitment to the care process obtained. This requires effective communication between the patient and the healthcare professional.
  3. Differential diagnosis—a simple screening questionnaire can be used for the initial diagnosis of headache subtypes.10 The questions are based on diagnostic criteria defined by the International Headache Society (IHS).3 If necessary, additional questions can be used to confirm the diagnosis.
  4. Assessment of illness severity—headache can be categorised as mild to moderate or moderate to severe based on data on disability, headache frequency and duration, pain severity, non-pain symptoms, patient preferences, and co-morbidities.
  5. Tailoring management to the needs of the individual patient— treatments should be provided that are appropriate to the patient’s needs, using, wherever possible, evidence from randomised, controlled (Grade A) clinical studies.
  6. Proactive, long-term follow up—a long-term strategy is required for the management of all headaches. Procedures need to be implemented to assess the patient’s pattern of headaches and their response to therapy. For success, long-term commitment from both the patient and the healthcare provider is required.
  7. A team approach to care—the management of headache requires a multidisciplinary approach: the GP concentrates on accurate diagnosis and prescription of appropriate treatments; the practice nurse forms the first point of contact for the patient and conducts routine assessment procedures. Other healthcare professionals (e.g. pharmacists, opticians, and dentists) may identify patients in the general population and either treat them or refer them to the GP.

Treatment pathways

The treatment pathways for headache management currently used in the UK are shown in Figure 1.11 All patients attend a primary care service for initial assessment and diagnosis. The diagnosis then drives the choice of care and care provider. Most patients with a TTH can be managed in the pharmacy, while those with migraine can be successfully treated by primary care.1,8

Patients with atypical migraine symptoms or who are refractory to treatment, together with those with CDH and cluster headache may be referred to a GP with Special Interest (GPwSI) in headache, based in primary care or a hospital. Patients with possible sinister headaches and those in whom the diagnosis is uncertain should be referred to a secondary/tertiary care headache specialist or neurologist. Individuals with refractory headaches may also eventually need to be referred to secondary care. This model provides an integrated headache service, with most patients managed successfully in primary care.

Figure 1: Pathways of care for headache management11*

figure 1
*These pathways of care link pharmacists, GPs, GPwSI in headache, and secondary and tertiary care physicians in the UK
TTH=tension-type headache
Reproduced with kind permission of MIPCA

Treatment selection in primary care

Any co-morbidities and concurrent medicines must always be checked, as these may preclude other treatments; for example, asthma sufferers should not be given aspirin or non-steroidal anti-inflammatory drugs (NSAIDs). On the other hand, patients with concurrent epilepsy or depression may be treated with topiramate or amitriptyline, respectively.

Episodic tension-type headache

Episodic tension-type headache can usually be managed with over-the-counter analgesics (e.g. paracetamol, aspirin, and NSAIDs). If one analgesic is ineffective, another may be tried.


Migraine can be treated with acute or preventive medicine. Attacks (especially those of mild-to-moderate intensity) may be managed acutely with analgesics (paracetamol, aspirin, NSAIDs, or combination analgesics), which have all been proved to be effective in controlled clinical trials (Grade A clinical evidence).12 Analgesics should be taken as soon as possible after the migraine attack starts, and if possible, before the onset of the headache.8 However, the frequent use (>1 day per week) of codeine-containing analgesics is inadvisable, due to the associated risk of developing CDH.2 Alternative treatments should be selected for such patients.

Triptans are the gold standard acute treatment for migraine, and are especially useful for moderate-to-severe intensity attacks, and when analgesics have proved ineffective. All triptans have been found to be effective in controlled clinical trials (Grade A clinical evidence).12 A range of triptans are available in a number of formulations (see Table 3). These drugs should be taken as soon as possible after the onset of headache, if possible when it is mild in intensity.8 Triptans should be used with caution in conditions that predispose the patient to coronary artery disease and are contraindicated in certain heart conditions, and uncontrolled or severe hypertension.

Patients with frequent disabling attacks and those who have failed on, or who cannot use, acute medicine may be prescribed preventive medicine.13 In the UK this is usually in the form of a beta blocker (e.g. propranolol), an anti-epileptic drug (e.g. topiramate), pizotifen, or a tricyclic antidepressant (e.g. amitriptyline).12 Tricyclic antidepressants should be used with caution; although they have been shown to be effective, they are not licensed for migraine in the UK.12 None of these preventive treatments is 100% effective and acute drug treatment, such as triptans and analgesics, may therefore be co-prescribed.

Some non-drug therapies are also useful as adjuncts to prescribed treatments:12

  • lifestyle options—such as regular sleep-waking habits and stress reduction
  • behavioural therapies—such as relaxation and biofeedback
  • complementary therapies—such as feverfew, butterbur root extract, magnesium, and vitamin B2.

Table 3: Available triptans and their different formulations

Triptan Formulation

Conventional tablets

Orally disintegrating tablet formulations*

Subcutaneous injection

Nasal spray


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*These formulations are not absorbed in the mouth
†Also available from pharmacies in a 50 mg dose

Chronic daily headache

The evidence base for CDH treatments is relatively poor (Grade B/C evidence), but the following interventions are often successful in the clinic:

  • physical therapy to the neck if there is any stiffness there
  • withdrawal of abused medicines and treatment of any subsequent withdrawal symptoms
  • headache prophylaxis, together with the provision of acute medicines as rescue therapy.2

GP education

Implementation of a primary care headache service requires significant investment at the healthcare provider level. General practitioners and prospective GPwSIs require education on headache management from GP support organisations, and personal and financial support from the PCT. Fortunately, there is now a good supply of educational material, and many training courses and initiatives are available.

Educational materials

Educational modules for the GP with an interest in headache and the prospective GPwSI have been developed by MIPCA and are available from the website (www.mipca.org.uk). Useful educational materials are also available from the British Association for the Study of Headache (BASH) (www.bash.org.uk), the Migraine Trust charity (www.migrainetrust.org) and the Migraine Action Association patient support group (www.migraine.org.uk). Another source of information is the journal Headache Care; recent articles have included: competencies for GPwSIs in headache,14 and identifying patients who require specialist investigations.15


A postgraduate course on headache management, suitable for the professional development of GPwSIs and other healthcare professionals interested in headache, is shortly to be launched by the University of Central Lancashire in conjunction with MIPCA.


The Royal Society College for General Practitioners has several ongoing initiatives, including the Clinical Champions for many areas including prescribing and headache. In addition, an 18-week programme for headache management is in preparation, in conjunction with those for other important clinical conditions. An updated GPwSI document and an 18-week commissioning pathway guidance document are also available.16,17

MIPCA looks forward to a similar level of intellectual and economic investment from PCTs and the Government.

Future guidance

The Scottish Intercollegiate Guidelines Network is expected to publish a guideline for the diagnosis and management of headache in adults later this month (www.sign.ac.uk). It is expected that SIGN, BASH, and MIPCA guidelines will be updated as new information becomes available.


Most types of headache are eminently suited for management in primary care, particularly the benign primary headaches of episodic TTH, episodic migraine, and CDH. An integrated set of headache management guidelines has been prepared that define the responsibilities of, and interactions between, the different primary care services. Treatments are recommended based on the best available evidence from randomised and controlled clinical studies. In addition, a wide range of educational materials is available to cater for the different needs of primary care practitioners. Significant intellectual and economic investment from healthcare providers is now required to ensure that the best possible service is provided to patients.

Click here for CPD questions on this article and the MIPCA guidelines on the management of headache and migraine



  • Headache is a common event but only rarely has a sinister cause
  • The fear that headaches are arising from a serious underlying cause often prompts a neurological referral
  • Using a care pathway with clear prompts for referral could help to reduce unnecessary referrals
  • A care pathway for persistent/atypical headache is available on the 18-week wait website (www.18weeks.nhs.uk)
  • PBC consortia could commission community headache clinics staffed by GPs with an interest and/or GPwSIs and nurses
  • Tariff costs neurology outpatient = £194 (new), £96 (follow up)
  1. Glover C, Greensmith S, Ranftler A et al. Guidelines for community pharmacists on the management of headaches. Pharmaceutical J 2008; 280: 311-317.
  2. Dowson A, Bradford S, Lipscombe S et al. Managing chronic headaches in the clinic. Int J Clin Pract 2004; 58 (12): 1142-1151.
  3. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders; 2nd Edition. Cephalalgia 2004; 24 (Suppl 1): 1-151.
  4. Migraine in Primary Care Advisors. Managing chronic headaches in the clinic. Guildford: MIPCA, 2004.
  5. Tepper S, Rapoport A, Sheftell F, Bigal M.Chronic daily headache–an update. Headache Care 2004; 1 (4): 233-245.
  6. Rasmussen B, Jensen R, Schroll M, Olesen J.Epidemiology of headache in a general population–a prevalence study. J Clin Epidemiol 1991; 44 (11): 1147-1157.
  7. Steiner T, Scher A, Stewart W et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia 2003; 23 (7): 519-527.
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  10. Dowson A, Turner A, Kilminster S et al. Development and validation of the headache Diagnostic Screening Questionnaire (DSQ): a new questionnaire for the differential diagnosis of headache for use in primary care. Headache Care 2005; 2 (2): 111-118.
  11. Sender J, Bradford S, Watson D et al. General Practitioners with a Special Interest (GPwSI) in headache: setting up a specialist headache clinic in primary care. Headache Care 2004; 1 (3): 165-171.
  12. Dowson A, Kilminster S, Peters M et al. Understanding the evidence: evaluating the efficacy of migraine medications in clinical practice. Headache Care 2005; 2 (3): 133-144.
  13. British National Formulary. BNF 56. London: Royal Pharmaceutical Society, 2008.
  14. Dowson A, Lipscombe S, Watson D et al. A competencies framework for general practitioners with a special interest in headache: guidance from the Migraine in Primary Care Advisors and the Royal College of General Practitioners. Headache Care 2006; 3: 91-102.
  15. Dowson A, Bradford S, Watson D et al. The need for investigations in patients with headache: expert statement from the Migraine in Primary Care Advisors (MIPCA) for the GP and GP with Special Interest in Headache (GPSIH). Headache Care 2008; in press.
  16. Department of Health. Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services: headache. London: DH, 2003.
  17. Department of Health. 18 Week commissioning pathway – persistent atypical headache. London: DH, 2008. www.18weeks.nhs.uk G