The SIGN guideline on headache management will be of interest to many healthcare professionals, says Dr Andrew Dowson

Headache is a common condition, which accounts for around 4% of all consultations in primary care—around 6 million people in the UK are affected by migraine, and, at any one time, 40% of the population have tension-type headache.1 In November 2008, SIGN published a full guideline1 and quick reference guide2 on the Diagnosis and management of headache in adults. Prior to this, the main pieces of guidance available to the UK physician for the management of headache included:

  • comprehensive diagnostic criteria from the International Headache Society (IHS)3
  • evidence-based criteria from the Migraine in Primary Care Advisors (MIPCA) guidelines on the management of migraine,4 and chronic headaches5
  • consensus-based criteria from the British Association for the Study of Headache (BASH) on the management of migraine, tension-type headache (TTH), cluster headache, and medication overuse headache (MOH).6

Although collectively these documents provided comprehensive guidance, it was not always consistent or user-friendly for the physician managing a patient with headache.3–6 The SIGN guideline, which has incorporated material from the three sources listed above, may therefore have the potential to become the 'one-stop' source of information on headache for the physician. In this article I have provided my personal view on how well the SIGN guideline fulfils this requirement.

Who should refer to the guideline?

The full guideline covers the topic of headache in great detail and may be best suited for use by secondary care physicians, GPs with a Special Interest (GPwSIs) in headache, and for postgraduate physicians who are teaching.1 The quick reference guide is eminently suited for use by GPs, pharmacists, and other healthcare professionals.2 The MIPCA guidelines promote nurses as first-line healthcare providers for headache and,4,5,7 although not mentioned by SIGN, they would also be appropriate users of the quick reference guide.

Remit of the guideline

Headache is a condition that exerts a significant burden on both primary and secondary care services. There are a number of problems associated with the diagnosis and management of headache in primary care, including:

  • its differential diagnosis often proves to be difficult, and can lead to unnecessary referrals
  • analgesic treatments that are ineffective and/or cause undesirable side-effects (including headache), are sometimes still prescribed despite effective treatments being available for most headache subtypes
  • many patients do not consult a GP for headache and instead self-medicate with inappropriate analgesics.

The SIGN guideline was designed to provide recommendations based on current evidence for best practice; as well as focusing on primary headaches, it also includes material on secondary headaches that are likely to be encountered in primary care. The areas covered by the guideline are summarised in Box 1 . Due to the level of detail in the SIGN guideline, it is not possible to summarise every recommendation in this short article. The reader is referred to the quick reference guide,2 which describes the diagnosis and treatment of the headache subtypes in a manner that is easy to understand and use. The full guideline and quick reference guide are a comprehensive source of information for the GP interested in headache.

Box 1: Areas covered by the SIGN guideline on the diagnosis and management of headache1

The SIGN guideline discusses and provides recommendations for:
  • Signs, symptoms, and definitions of common headache subtypes that can be used in differential diagnosis, including tools that can be used to aid diagnosis and management
  • Specialised investigations that can be used for patients with headache and provides definitions of those patients who may require these procedures
  • Treatments (acute and preventive) for the common primary headaches: migraine, TTH, and trigeminal autonomic cephalalgias such as cluster headache
  • Identification of 'red flags' that indicate possible secondary headaches, which require immediate referral
  • Assessment and treatment of MOH, which is commonly associated with the chronic forms of migraine and TTH
  • Management of headaches associated with pregnancy, contraception, menstruation, and the menopause
  • Prevention of headache through lifestyle, psychological, physical, and complementary therapies
TTH=tension-type headache; MOH=medication overuse headache

Quality of the evidence

This new guideline on headache has a high status, good credibility, and is kitemarked with the SIGN and NHS Quality Improvement Scotland logos; it meets the best standards with respect to quality of evidence used and the peer-review process. The methodology used is similar to that employed for the MIPCA guidelines on migraine4 and chronic headache,5 but the SIGN version covers a wider range of headaches. The only small caveat is that most of the evidence analysed for the SIGN guideline covers only the last 6 years. Many headache treatments, which are supported by high-quality evidence, were developed before 2001 (e.g. sumatriptan for migraine and cluster headache).

The SIGN guideline mentions only three assessment tools for headache (as well as headache diaries): the Headache Impact Test (HIT) (assesses headache impact/disability),8 the Migraine Disability Assessment (MIDAS) Questionnaire (assesses headache impact/disability),9 and the ID Migraine questionnaire (for migraine only).10 Many other assessment tools are available for diagnostic purposes to assess the quality of life and other endpoints, and the success of interventions, but the SIGN guideline fails to mention them. Indeed, this field deserves its own dedicated publication.


The new SIGN guideline provides evidence-based and user-friendly recommendations for healthcare professionals on best practice for the management of most headache types in adults. Patients with rare headaches,those in whom diagnosis is uncertain, and those who fail on different types of interventions, or who fail repeatedly on the same intervention, may require care beyond this guideline and referral to a specialist physician.

The SIGN guideline provides the most recent, and best, one-stop source of information on headache. It should be used in conjunction with other materials because, in the field of headache, some data important to clinical practice was published many years ago, and therefore their consideration might have been beyond the remit of SIGN. In addition, the study of headache is rapidly evolving and it is likely that new research will modify practice and this guideline will need regular updating.

I am sure that the guideline will be warmly welcomed by all physicians who manage patients with headache, and SIGN is to be congratulated for allowing the documents to be freely available for downloading from their website: It is to be hoped that their use will not be restricted to Scotland, but will be implemented in the UK and internationally.


  1. Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. A national clinical guideline. SIGN 107. Edinburgh: SIGN, 2008. Available at
  2. Scottish Intercollegiate Guidelines Network. Diagnosis and management of headache in adults. Quick Reference Guide. SIGN 107. Edinburgh: SIGN, 2008. Available at
  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. Dowson A, Lipscombe S, Sender J et al. New guidelines for the management of migraine in primary care. Curr Med Res Opin 2002; 18 (7): 414–439.
  5. Dowson A, Bradford S, Lipscombe S et al. Managing chronic headaches in the clinic. Int J Clin Pract 2004; 58 (12): 1142–1151.
  6. British Association for the Study of Headache (BASH). Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. 3rd Edition. Hull: BASH, 2007. Also available at:
  7. Leech J, Dungay J, Dowson A. Headache management in primary care. Primary Health Care 2006; 16: 25–31.
  8. Kosinski M, Bayliss M, Bjorner J et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res 2003; 12: 963–974.
  9. Stewart W, Lipton R, Kolodner K et al. Reliability of the migraine disability assessment score in a population-based sample of headache sufferers. Cephalalgia 1999; 19: 107–114.
  10. Lipton R, Dodick D, Sadovsky R et al. A self-administered screener for migraine in primary care. Neurology 2003; 61: 375–382.G