Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre (NCGC) on behalf of the National Institute for Health and Clinical Excellence (NICE) (see the "Availability of Companion Documents" field for the full version of this guidance).
Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral*:
- 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
- A substantial change in the characteristics of their headache
Consider further investigations and/or referral for people who present with new-onset headache and any of the following:
- Compromised immunity, caused, for example, by human immunodeficiency virus (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
Tension-Type Headache, Migraine (With or Without Aura) and Cluster Headache
Diagnose tension-type headache, migraine or cluster headache according to the headache features in the table.
Table: Diagnosis of Tension-Type Headache, Migraine and Cluster Headache
||Migraine (With or Without Aura)
||Unilateral or bilateral
||Unilateral (around the eye, above the eye and along the side of the head/face)
||Pulsating (throbbing or banging in young people aged 12–17 years)
||Variable (can be sharp, boring, burning, throbbing or tightening)
||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
||Unusual sensitivity to light and/or sound or nausea and/or vomiting
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
||4–72 hours in adults
1–72 hours in young people aged 12–17 years
|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
||1 every other day to 8 per day3, with remission4 >1 month
||1 every other day to 8 per day3, with a continuous remission4 <1 month in a 12-month period
||Episodic tension-type headache
||Chronic tension-type headache5
||Episodic migraine (with or without aura)
||Chronic migraine6 (with or without aura)
||Episodic cluster headache
||Chronic cluster headache
1 Headache pain can be felt in the head, face or neck.
2 See the recommendations below for further information on diagnosis of migraine with aura.
3 The frequency of recurrent headaches during a cluster headache bout.
4 The pain-free period between cluster headache bouts.
5 Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.
6 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
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 5–60 minutes
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 for suspecting aura above:
- 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
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 for suspecting aura above:
- Motor weakness or
- Double vision or
- Visual symptoms affecting only one eye or
- Poor balance or
- Decreased level of consciousness
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 (see the recommendations concerning headache diary in the section "Assessment" above) for at least 2 menstrual cycles.
Medication Overuse Headache
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 a non-steroidal anti-inflammatory drug (NSAID), either alone or in any combination, on 15 days per month or more
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
Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the features listed in the first bulleted list under "Assessment" above.
Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.
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
Give the person written and oral information about headache disorders, including information about support organisations.
Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder.
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.
Do not offer opioids for the acute treatment of tension-type headache.
Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.
Migraine With or Without Aura
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.
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.
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.
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:
- Offer a non-oral preparation of metoclopramide or prochlorperazine†
- Consider adding a non-oral NSAID or triptan† if these have not been tried
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.
Offer topiramate† or propranolol for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate† is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.
If both topiramate† and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin† (up to 1200 mg per day) according to the person's preference, comorbidities and risk of adverse events.
For people who are already having treatment with another form of prophylaxis such as amitriptyline†, 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.
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.
For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with frovatriptan† (2.5 mg twice a day) or zolmitriptan† (2.5 mg twice or three times a day) on the days migraine is expected.
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.
Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.
Discuss the need for neuroimaging for people with a first bout of cluster headache with a general practitioner (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.
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.
Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache.
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.
Seek specialist advice for cluster headache that does not respond to verapamil†.
Seek specialist advice if treatment for cluster headache is needed during pregnancy.
Medication Overuse Headache
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.
*For information on referral for suspected tumours of the brain or central nervous system see Referral guidelines for suspected cancer (NICE clinical guideline 27); update under development (publication date to be confirmed).
**Because of an association with Reye's syndrome, preparations containing aspirin should not be offered to people aged under 16 years.
†At the time of publication (September 2012), the following drugs did not have a United Kingdom (UK) marketing authorisation for the indication presented in the guideline:
- Triptans (except nasal sumatriptan) in people aged under 18 years
- Prochlorperazine (except for the relief of nausea and vomiting)
- Topiramate in people under 18 years
- Riboflavin (available as a food supplement. When advising this option, the prescriber should take relevant professional guidance into account.)
- Subcutaneous triptans in people aged under 18 years
- Nasal triptans
The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.