Dr Kay Kennis outlines the NICE guideline on the diagnosis and treatment of tension-type headache, migraine, cluster headache, and medication-overuse headache
  • Beware of diagnosing a primary headache if there are warning features to suggest a serious underlying cause
  • Primary headaches are far more common than serious secondary headaches—a diagnosis should be made if clinical features fit and there are no abnormal neurological symptoms or signs
  • Exclude medication-overuse headache before making a diagnosis of primary headache
  • Neuroimaging should not be requested solely for reassurance if there is a clear diagnosis of migraine or tension-type headache
  • Explain the diagnosis clearly to the patient and recognise that they have a genuine medical condition
  • Ensure all patients with primary headache are warned about the risk of medication overuse headache
  • Consider the need for combined triptan plus paracetamol or non-steroidal anti-inflammatory drug early in acute treatment of migraine
  • Consider the use of topiramate as a first-line prophylactic for migraine; propranolol is an alternative first-line option
  • Ensure patients with cluster headache have a sufficient supply of intranasal or subcutaneous triptan
  • Ensure all patients with cluster headache have access to home and ambulatory high-flow oxygen, with a non-rebreathing mask and reservoir bag.

NICE Clinical Guideline 150 on Headaches: diagnosis and management of headaches in young people and adults has been awarded the NHS Evidence Accreditation Mark.

This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.

Headache disorders are very common in the UK: 15% of the UK adult population is affected by migraine and 1% will experience cluster headache at some point in their lives.1 Headache accounts for 1 in 25 (4%) of all GP consultations each year and 30% of neurology referrals.2,3 In September 2012, NICE published its first clinical guideline for the NHS on the diagnosis and management of the most common primary headaches and medication-overuse headache (Clinical Guideline [CG] 150).4 A key message within the guidance is that the majority of individuals with headache can be diagnosed and managed in primary care. General practitioners can lack confidence in diagnosing the common primary headaches, and may be fearful of missing a sinister underlying pathology. Therefore, the NICE guideline will empower the profession to make a diagnosis and determine appropriate management options.

NICE CG150 covers the diagnosis and treatment of tension-type headache, migraine, and cluster headache; and it emphasises the importance of recognising and managing medication-overuse headache, as this is the most common secondary type of headache. The guideline also includes recommendations on:4

  • the management of menstrual-related migraine
  • the management of headache in pregnancy
  • contraceptive choices in patients with migraine
  • seeking specialist advice from a GP with a Special Interest in Headache or a consultant neurologist with a similar interest.

NICE CG150 is the first evidence-based guideline to take into account both the clinical and cost-effectiveness of therapies for headache. Unless specifically stated otherwise, all of the recommendations apply to adults and young people aged 12 years and over.4 The guideline will help to promote best practice in primary care and improve the care of patients, without the need for substantial additional resources.

This article discusses key recommendations from the guideline that are relevant to primary care physicians. To read the full recommendations, please visit: www.nice.org.uk/CG150


Assessment

Evaluate warning symptoms and signs

At the first consultation, GPs should evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral:4

  • 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 last 3 months) head trauma
  • headache triggered by cough, valsalva, or sneeze
  • headache triggered by exercise
  • orthostatic headache
  • symptoms suggestive of giant cell arteritis
  • symptoms and signs of acute narrow-angle glaucoma
  • a substantial change in the characteristics of their headache.

Healthcare professionals should also exercise caution if the patient has a previous history of malignancy (particularly if under the age of 20 years), has a history of cancer known to metastasise to the brain, is immunocompromised, or has vomiting without another obvious cause. Individuals with migraine and atypical aura may also require further evaluation.4

If warning features are present, GPs should not make an immediate diagnosis of a primary headache disorder; instead they should consider whether further investigation or specialist referral may be required.4

Exclude medication overuse

Medication overuse is a common cause of chronic headache, which can mask the underlying diagnosis. It has been estimated that approximately 1%–2% of the population experience headaches caused by medication overuse.5 General practitioners should suspect medication overuse if the patient has used analgesics regularly for their primary headache disorder, which includes use of the following for ?3 months:4

  • ergots, opioids, triptans, or combination analgesic medications on ?10 days per month
  • aspirin, non-steroidal anti-inflammatory drug (NSAID), or paracetamol on ?15 days per month.

Diagnose the primary headache disorder

Diagnosis of the three main primary headaches—tension-type headache, migraine, and cluster headache—should be made according to the key features summarised in Table 1.4 It may be useful to ask the patient to use a headache diary for a minimum of 8 weeks.4

Consider neuroimaging

NICE recommends that neuroimaging should not be requested solely for reassurance when there is a clear diagnosis of migraine or tension-type headache.4 There was no evidence to suggest that patients had lower anxiety or depression scores after a scan. Furthermore, there was a high occurrence of incidental abnormalities—10% in one study of general practice.6 Such findings are often minor, but may cause significant anxiety.

The effectiveness of scanning is unproven in patients with their first bout of cluster headache and NICE recommends specialist referral to a GP with a Special Interest in Headache or a neurologist. Imaging is not required for patients with long-standing cluster headache.4


Table 1: Diagnosis of tension-type headache, migraine, and cluster headache4

Headache feature*

Tension-type headache

Migraine (with or without aura)

Cluster headache

Pain location

Bilateral

Unilateral or bilateral

Unilateral (around the eye, above the eye and along the side of the head/face)

Pain quality

Pressing/tightening (non-pulsating)

Pulsating (throbbing or banging in young people aged 12–17 years)

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

Pain intensity

Mild or moderate

Moderate or severe

Severe or very severe

Effect on activities

Not aggravated by routine activities of daily living

Aggravated by, or causes avoidance of, routine activities of daily living

Restlessness or agitation

Other symptoms

None

Unusual sensitivity to light and/or sound or nausea and/or vomiting

Aura (please refer to CG150 for further information on diagnosis of migraine with aura)

Symptoms 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

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

Duration of headache

30 minutes–continuous

4–72 hours in adults

1–72 hours in young people aged 12–17 years

15–180 minutes

Frequency of headache

<15 days per month

?15 days per month for more than 3 months

<15 days per month

?15 days per month for more than 3 months

One every other day to eight per day, with remission >1 month

One every
other day to
eight per day, with a continuous remission <1 month in a 12-month period

Diagnosis

Episodic tension-type headache

Chronic tension-type headache§

Episodic migraine (with or without aura)

Chronic migraine| (with or without aura)

Episodic cluster headache

Chronic cluster headache

* Headache pain can be felt in the head, face or neck
 The frequency of recurrent headaches during a cluster headache bout
 The pain-free period between cluster headache bouts
§ Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine
| NICE has developed technology appraisal guidance on botulinum toxin type A for the prevention of headaches in adults with chronic migraine
 (headaches on at least 15 days per month of which at least 8 days are with migraine [Technology Appraisal 260])

National Institute for Health and Care Excellence. Headaches: diagnosis and management of headaches in young people and adults.
Clinical Guideline 150. London: NICE, 2012. Reproduced with kind permission from NICE. Available at: www.nice.org.uk/CG150


General management principles

NICE recommends the following general principles for the management of all headache types:4

  • provide an explanation of the diagnosis
  • reassure the patient that their headache is not secondary to a more serious underlying disorder
  • empathise and discuss the validity of the diagnosis—patients often feel that their symptoms are not believed by work colleagues and medical professionals as they are unable to present when having an attack
  • discuss management options (see below)
  • warn about the risk of medication-overuse headache
  • arrange appropriate follow up to review treatment and evaluate any change to symptoms; the use of a headache diary may aid review
  • direct the patient to evidence-based information and support (see guidance from NICE in the ‘information for the public’ document7).

It should be noted that at the time of publication of CG150, some drugs did not have a UK marketing authorisation for indications recommended in the guideline. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent from the patient (or carer) for off-label use should be obtained and documented.4

Migraine

Acute treatment

A combination of a triptan and NSAID or a triptan and paracetamol has been shown to be superior to monotherapy for the treatment of headache.1 This differs from the ‘step-up’ approach to acute medication that has been advocated previously by bodies such as the British Association for the Study of Headache, and Scottish Intercollegiate Guidelines Network. If patients have side-effects or contraindications to combination therapy, or prefer to take only one drug, then monotherapy can be used.

Aspirin (up to 900 mg), an NSAID, a triptan, or paracetamol are all appropriate monotherapy options for acute treatment. Healthcare professionals should consider a nasal triptan in preference to an oral triptan in young people aged 12–17 years.4 The triptan with the lowest acquisition cost should be chosen initially, but others can be considered if this is not effective. An anti-emetic may be added and can increase the effectiveness of analgesics even if the patient has no nausea. The use of opioids and ergots is not recommended.4

If oral medication is not appropriate or not tolerated then intravenous or non-oral metoclopramide or prochlorperazine can be used. These medications have also demonstrated analgesic properties in trials,8,9 possibly due to their effects on dopamine receptors, and they may be a useful addition to the emergency drug bag. Non-oral NSAIDs or triptans may also be used if these have not already been tried.4

Prophylactic treatment

Prophylactic treatment can generally be be withdrawn after 6 months of good control.4 Topiramate and propranolol are first-line options for prophylactic treatment.4 Topiramate was the most clinically and cost effective medication;1 however, it is teratogenic and may not be appropriate for all patients. It may also interfere with some hormonal contraceptives (refer to Faculty of Sexual & Reproductive Healthcare guidance for current advice).10

If topiramate or propanolol are unsuitable or ineffective, up to 10 sessions of acupuncture over 5–8 weeks or up to 1200 mg per day of gabapentin can be considered. There was also evidence to recommend the use of riboflavin (400 mg once a day) to reduce migraine frequency and intensity.4

Patients who are well controlled on traditional prophylactics, such as amitriptyline, sodium valproate, and pizotifen should continue their current treatment as needed.4

NICE CG150 does not cover the use of botulinum toxin A for the prevention of chronic migraine as this has been the subject focus of NICE Technology Appraisal 260.11

Female patients of reproductive age who have migraine

NICE advises that combined hormonal contraception should not be used to prevent pregnancy in women who have migraine with aura because of the potential increased risk of ischaemic stroke.1,4

The use of medication should be minimised in pregnancy—women with migraine without aura should be reassured that generally migraine improves in the second and third trimesters of pregnancy.12,13 Paracetamol is the first-line acute medication;3 NSAIDs and triptans may be considered after careful discussion with the patient on the risks and benefits. Specialist referral is recommended if prophylaxis becomes necessary.4

Menstrual-related migraine can be particularly severe, and migraine at this time may not respond to the usual acute and prophylactic medications. There was limited evidence to support the prophylactic use of frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) under these circumstances.4 This strategy is not always effective and only possible if the menstrual period and the migraine are predictable.1


Acute treatment

Aspirin, paracetamol, or an NSAID are recommended for the acute treatment of tension-type headache. Opioids should not be used.4

Prophylactic treatment

There was insufficient evidence to recommend a pharmacological form of prophylactic treatment for tension-type headache; however a 10-session course of acupuncture over 5–8 weeks may be considered.4 The limited trial evidence was derived from studies using traditional Chinese acupuncture.

Migraine prophylactics can be used in people with a chronic daily headache
(i.e. headache on more than 15 days of the month), with features of both tension-type headache and migraine.4

Tension-type headache

Acute treatment

Oxygen or non-oral triptans are effective acute therapies for cluster headache, and patients may require both drugs. Triptans should be prescribed intranasally or subcutaneously as cluster headache does not respond to oral medication.4 Patients require an adequate supply, and can have the manufacturer’s maximum recommended dose in 24 hours, recurrently, seemingly without developing tachyphylaxis.1 Oxygen is prescribed using the home oxygen order form.1 The oxygen:1,4

  • must be high flow (at least 12 litres/ min)
  • should be given with a non-rebreathing mask and reservoir bag
  • should be provided in both home and ambulatory cylinders or patients risk being confined to the home during their cluster bout.

Prophylactic treatment

Verapamil is recommended as first-line prophylaxis but requires electrocardiogram (ECG) monitoring and advice should be sought from a specialist if the GP is not familiar with its use for cluster headache. It should be noted that patients on long-term verapamil should continue to have regular ECGs even if the dose remains constant. Healthcare professionals should seek specialist advice if patients do not respond to verapamil.4

Medication-overuse headache

Treatment of medication-overuse headache requires the overused medication to be stopped. This is challenging for patients and NICE recommends that it is done abruptly.4 Patients must stay off the overused medication for a minimum of 4 weeks. They should be warned that their headache will worsen in the first few weeks, before hopefully improving.3 Some clinicians prescribe regular NSAIDs (if these were not overused) or prophylactic medication routinely to aid withdrawal, but this is an area that requires further research.


Conclusion

The NICE guideline will aid the GP to diagnose the most common primary headaches confidently and give clear management strategies. It is hoped that the recommendations will standardise practice, and therefore improve patient care across the NHS. NICE has developed a tool set to support implementation of the guideline, which can be found here. Further information on CG150, including advice that can be given to patients, can be found at: www.nice.org.uk/CG150.


NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 150 (CG150) on Headaches: diagnosis and management of headaches in young people and adults. The tools are now available to download from the NICE website: www.nice.org.uk/CG150

NICE support for commissioners

Costing report Commissioning.eps

Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Costing template Commissioning.eps

Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

NICE support for service improvement systems and audit

Baseline assessment tool Audit.eps

The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Clinical audit tools Audit.eps

Clinical audit tools are developed to help with clinical audit. They contain clinical audit standards, a data collection form, and an action plan template.

NICE support for education and learning

Academic detailing aid Education.eps

NICE academic detailing aids are designed for prescribing and medicines management personnel to support discussions with prescribers on key prescribing and medicines optimisation messages.

CG150 Headaches: diagnosis poster Education.eps

This poster has been adapted from the table in section 1.2 of CG150. The poster has been developed to support clinicians in diagnosing primary headaches.

Clinical case scenarios Education.eps

Clinical case scenarios are an educational resource designed to improve and assess users’ knowledge of the guideline on the management of headaches.

Key to NICE implementation icons
 Commissioning.eps NICE support for commissioners
  • Support package for commissioners and others for quality standards
  • NICE guide for commissioners
  • NICE cost impact support for guidance (selection from national report/local template/costing statement, dependent on topic)
 Audit.eps NICE support for service improvement systems and audit
  • Forward planner
  • 'How to' guides (generic advice on processes)
  • Local government briefings (with Centre for Public Health Excellence)
  • Baseline assessment tool for guidance
  • Audit support including electronic data collection tools
  • E-learning modules (commissioned)
 Education.eps NICE support for education and learning
  • Clinical case scenarios
  • Learning packages including slide sets
  • Podcasts
  • Shared learning and other local best practice examples

  • This NICE guideline forms the basis for the design of a local care pathway for headaches in younger people and adults to ensure individuals who need onward referral or investigations receive them promptly, and those who do not need referral obtain responsive treatment in primary care
  • If scans are indicated, these could be commissioned using an Any Quality Provider scheme
  • Commissioners should ensure that there is a choice of formulary drugs for migraine therapies and that these are of low acquisition cost
  • Commissioners could consider use of a GPwSI or community based headache clinic to give GPs a referral source for further advice while avoiding expensive Payment by Results tariff costs
  • Commissioners could consider targeted work with pharmacies who sell analgesics to alert patients to the possibility of medication overuse headache and provide suitable advice
  • Tariff costs:a
    • neurology outpatient = £225 (new) (WF01B), £130 (follow up) non-mandatory; WF01A)
    • magnetic resonance imaging scan with report = £175 (RA01Z), computed tomography scan = £107 (no contrast with report; RA08Z).

awww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132654

  1. National Clinical Guideline Centre. Diagnosis and management of headaches in young people and adults. London: NCGC, 2012. Available at: www.nice.org.uk/CG150 nhs_accreditation
  2. Lambeth Practice Based Commissioning Collaborative (LPBCC) (Guideline Ref ID Lambeth 2011).
  3. Yorkshire Wolds and Coast Primary Care Trust, Scarborough WaRPCT, Scarborough and North Coast Yorkshire Healthcare NHS Trust. (Guideline Ref ID Scarborough 2006).
  4. National Institute for Health and Care Excellence. Headaches: diagnosis and management of headaches in young people and adults. Clinical Guideline 150. London: NICE, 2012. Available at: www.nice.org.uk/CG150 nhs_accreditation
  5. Russell M, Lundqvist C. Prevention and management of medication overuse headache. Curr Opin Neurol 2012; 25 (3): 290–295.
  6. Thomas R, Cook A, Taylor T et al. Primary care access to computed tomography for chronic headache. Br J Gen Pract 2010; 60 (575): 426–430.
  7. National Institute for Health and Care Excellence website. Information for the public: Headaches. publications.nice.org.uk/headaches-ifp150 (accessed 5 November 2012).
  8. Brousseau D, Duffy S, Anderson A, Linakis J. Treatment of pediatric migraine headaches: a
    randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emergency Medicine 2004; 43 (2): 256–262.
  9. Friedman B, Corbo J, Lipton R et al. A trial of metoclopramide vs sumatripan for the emergency department treatment of migraines. Neurology 2005; 64 (3): 463–468.
  10. Faculty of Sexual & Reproductive Healthcare website. Clinical guidance. www.fsrh.org/pages/Clinical_Guidance_4.asp (accessed 30 October 2012).
  11. National Institute for Health and Care Excellence. Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. Technology Appraisal 260. London: NICE, 2012. Available at: www.nice.org.uk/TA260 nhs_accreditation
  12. Maggioni F, Alessi C, Maggino T, Zanchin G. Headache during pregnancy. Cephalalgia 1997; 17 (7): 765–769.
  13. Silberstein S. Migraine and pregnancy. Neurologic Clinics 1997; 15 (1): 209–231. G