All headache disorders

• Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. [2012]

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. [2012]

Migraine with or without aura

Prophylactic treatment

• 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 contraceptive with a barrier method).

  Follow the MHRA safety advice on antiepileptic drugs in pregnancy. [2015, amended 2021]

  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.

Cluster headache

Tension-type headache, migraine (with or without aura) and cluster headache

1.2.1.

Diagnose tension-type headache, migraine or cluster headache according to the headache features in table 1. Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.

See recommendations 1.2.2, 1.2.3 and 1.2.4 for more information on diagnosis of migraine with aura. [2012]

Episodic tension-type headaches occur on fewer than 15 days per month. Chronic tension-type headaches occur on 15 or more days per month for more than 3 months.

Episodic migraines (with or without aura) occur on fewer than 15 days per month. Chronic migraines (with or without aura) occur on 15 or more days per month for more than 3 months.

Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month. Chronic cluster headaches occur from once every other day to 8 times a day with a continuous pain-free period of less than 1 month in a 12-month period.

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).

Migraine with aura

1.2.2.

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 to 60 minutes. [2012]

1.2.3.

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 in recommendation 1.2.2:

• 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. [2012]

1.2.4.

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 in recommendation 1.2.2:

• motor weakness or
• double vision or
• visual symptoms affecting only one eye or
• poor balance or
• decreased level of consciousness. [2012]

Menstrual-related migraine

1.2.5.

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. [2012]

1.2.6.

Diagnose menstrual-related migraine using a headache diary (see recommendation 1.1.4) for at least 2 menstrual cycles. [2012]

Medication overuse headache

1.2.7.

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 NSAID, either alone or in any combination, on 15 days per month or more. [2012]

All headache disorders

1.3.1.

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. [2012]

1.3.2.

Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the features listed in recommendation 1.1.1. [2012]

1.3.3.

Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. [2012]

Tension-type headache

Migraine with or without aura

Cluster headache

Medication overuse headache

1.3.36.

Explain to people with medication overuse headache that it is treated by withdrawing overused medication. [2012]

1.3.37.

Advise people to stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually. [2012]

1.3.38.

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. [2012]

1.3.39.

Consider prophylactic treatment for the underlying primary headache disorder in addition to withdrawal of overused medication for people with medication overuse headache. [2012]

1.3.40.

Do not routinely offer inpatient withdrawal for medication overuse headache. [2012]

1.3.41.

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. [2012]

1.3.42.

Review the diagnosis of medication overuse headache and further management 4 to 8 weeks after the start of withdrawal of overused medication. [2012]

Acute narrow-angle glaucoma

An uncommon eye condition that results from blockage of the drainage of fluid from the eye. Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi-dilated pupil compared with the presence of a constricted pupil in cluster headache.

Cluster headache bout

The duration over which recurrent cluster headaches occur, usually lasting weeks or months. Headaches occur from 1 every other day to 8 times per day.

Giant cell arteritis

Also known as temporal arteritis, giant cell arteritis is characterised by the inflammation of the walls of medium and large arteries. Branches of the carotid artery and the ophthalmic artery are preferentially involved, giving rise to symptoms of headache, visual disturbances and jaw claudication.

NSAID

Non-steroidal anti-inflammatory drug.

Positive diagnosis

A diagnosis based on the typical clinical picture that does not require any further investigations to exclude alternative explanations for a patien’s symptoms.

Why this is important

Effective prevention has the potential to make a major impact on the burden of disability caused by recurrent migraine. There are few pharmacological agents that have been proven to prevent recurrent migraine.

Amitriptyline is widely used, off-label, to treat chronic painful disorders, including migraine. The updated evidence review (2015) found evidence comparing amitriptyline with topiramate, but not with placebo, and there was uncertainty about the effectiveness of amitriptyline as a prophylactic treatment. A double-blind randomised controlled trial (RCT) is needed to assess the clinical and cost effectiveness of amitriptyline compared with placebo. The definition of migraine used should be that in the International classification of headache disorders 2 or this guideline. Outcomes should include change in patient-reported headache days, responder rate and incidence of serious adverse events.

Why this is important

There are few data to inform guidance on the prevention of migraine in children and young people.

Pizotifen is a popular treatment for migraine prevention in the UK, especially in children and young people. It has been in use since the 1970s and appears to be well tolerated. Inadequate evidence was found in the review for this guideline for the effectiveness of pizotifen in the prophylaxis of migraine. A double-blind RCT either head-to-head with best available treatment, or placebo controlled, is needed to assess the clinical and cost effectiveness of pizotifen in young people aged under 18 and adults. The trial should enrol people aged under 18 and adults. The definition of migraine used should be that in the International classification of headache disorders 2 or this guideline. Outcomes should include change in patient-reported migraine days, responder rate and incidence of serious adverse events. If pizotifen is shown to be effective, it will widen the range of therapeutic options, in particular for young people in whom recommended medications are ineffective or not tolerated.

Why this is important

Cluster headache is an excruciatingly painful and highly disabling disorder. The management of cluster headache includes the use of preventive treatments to stop the attacks as quickly and safely as possible. There is a significant unmet clinical need for effective preventive treatments in cluster headache and few data to inform guidance on prophylaxis of cluster headache. Although numerous agents including verapamil, topiramate, lithium, methysergide and gabapentin are used in routine clinical practice, this is largely based on clinical experience as very few RCTs have been performed.

Several open-label studies have reported on the efficacy of topiramate in the preventive treatment of cluster headache. There is therefore a need for a high-quality RCT of topiramate in the prevention of cluster headaches.

Why this is important

Psychological interventions such as CBT are widely recommended for people with chronic painful disorders. An effective psychological intervention based on cognitive behavioural principles for people with chronic headache disorders has the potential to substantially improve their quality of life. There are few data to support the use of these interventions to manage chronic headache disorders.

A pragmatic RCT is needed to assess the impact of a psychological intervention compared with an active control. Mood disorders are commonly comorbid with headache disorders, but the trial needs to address the impact of a psychological intervention on headache alone, using appropriate headache outcomes such as change in patient-reported headache days and headache-specific quality of life.

Why this is important

Medication overuse headache is a common disorder. Current best advice is for abrupt withdrawal without any supportive pharmacological treatment. Many people with medication overuse headache find it difficult to withdraw abruptly because in the short term their headaches can become much worse. The use of steroids may aid withdrawal and for those who have an underlying headache disorder such as migraine or tension-type headache, appropriate prophylaxis may assist in treating the headache.

Double-blind RCTs are needed in people with suspected medication overuse headache who have an identifiable primary headache disorder. There should be two separate trials, one to investigate withdrawal of medication with placebo versus withdrawal of medication with steroid treatment, and the other to investigate withdrawal of medication with placebo versus withdrawal of medication with appropriate pharmacological prophylaxis. Outcomes should include change in acute medication use, proportion of patients who no longer have suspected medication overuse headache, change in patient-reported headache days and headache-specific quality of life.