Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, D, Good Practice Points) and level of the evidence (Level 1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are presented at the end of the "Major Recommendations" field.
The following is a list of major changes or additions to the updated guidelines:
- Recommendations from the US Headache Consortium have been integrated into these guidelines.
- A section on migraine has been added detailing the various forms of migraine and its treatment modalities.
- Psychological aspects of headaches have also been added to provide a psychological viewpoint.
- The section on secondary headaches has been expanded.
- Investigations for headaches have been streamlined for clarity.
- A new section has been added on tension type headaches.
- The dangers of medication overuse headaches are deemed important enough to warrant a section on their own.
- Alternative headache treatments, specifically acupuncture, have been added.
Tension Type Headaches
Diagnosis and Classification
GPP - The clinical diagnosis of tension-type headaches should be guided by the International Headache Society criteria (Headache Classification Subcommittee of the International Headache Society, 2004). (GPP)
Treatment
A & B - Simple analgesics and nonsteroidal anti-inflammatory drugs are effective and may be used for acute treatment of tension type headaches at the following doses (von Graffenried & Nuesch, 1980; Diamond, 1983; Langemark & Olesen, 1987; Martínez-Martín et al., 2001; Nebe, Heier, & Diener, 1995; Peters, Fraim, & Masel, 1983; Ryan, 1977; Steiner, Lange, & Voelker, 2003; Dahlof & Jacobs, 1996; Mehlisch, Weaver, & Fladung, 1998; Migliardi et al., 1994; Packman et al., 2000; Prior et al., 2002; Schachtel et al., 1991; Schachtel, Furey, & Thoden, 1996; Steiner & Lange, 1998; Miller et al., 1987; Diener et al., 2005; Schachtel & Thoden, 1988; van Gerven et al.,1996; Kubitzek et al., 2003)
Drugs |
Dosage |
Grade and Level |
Aspirin |
500-1000 mg |
Grade A, Level 1+ |
Paracetamol |
1000 mg |
Grade A, Level 1+ |
Ibuprofen |
200-400 mg |
Grade A, Level 1+ |
Ketoprofen |
25-50 mg |
Grade A, Level 1+ |
Naproxen |
375-550 mg |
Grade B, Level 1+ |
Diclofenac |
25 mg |
Grade B, Level 1+ |
A - Caffeine can be used as an analgesic adjuvant for acute treatment of tension-type headache (Migliardi et al., 1994; Schachtel et al., 1991; Diener et al., 2005; Diamond, Balm, & Freitag, 2000). (Grade A, Level 1+)
D - Medication overuse should be avoided as it increases the risk of developing chronic daily headache (Silberstein et al., 2005). (Grade D, Level 4)
D - Prophylactic treatment should be considered when headaches are frequent (Headache Classification Subcommittee of the International Headache Society, 2004). (Grade D, Level 4)
A - Amitriptyline 10-75 mg daily should be considered first for prophylactic treatment of tension-type headache (Schachtel & Thoden, 1988; Lance & Curran, 1964; Diamond & Baltes, 1971; Göbel et al., 1994; Cerbo et al., 1998; Bendtsen, Jensen, & Olesen, 1996). (Grade A, Level 1++)
B - Other locally available medications with less evidence of efficacy which may be used for prophylactic treatment of tension-type headache include:
Drugs |
Dosage and Frequency |
Grade and Level |
Clomipramine |
25-100 mg daily |
Grade B, Level 1+ |
Maprotiline |
25-75 mg daily |
Grade B, Level 1+ |
Mirtazapine |
15-30 mg daily |
Grade B, Level 1+ |
GPP - Medications for prophylactic treatment of tension-type headache should be started at low doses and titrated up to therapeutic doses to minimize adverse effects. (GPP)
Migraine
Diagnosis
C - A validated 3-item questionnaire (ID-Migraine) covering disability, nausea, and sensitivity to light should be used by primary care physicians if screening for migraine is required (Rapoport & Bigal, 2004; Lipton et al., 2003; Sadovsky & Dodick, 2005). (Grade C, Level 3)
Assessment of Disability
B - Standardized self-assessed questionnaires, e.g., The Migraine Disability Assessment (MIDAS), Headache Impact Test Questionnaire (HIT-6) (see Appendix 1 and 2 in the original guideline document), to determine migraine disability should be administered where practicable. (Grade B, Level 2++)
Treatment Principles
B - Stratified care strategies (tailoring drugs to headache severity) should be used in preference to step-care strategies (using drugs in a progressive predetermined way) within or across attacks because the former provides significantly better clinical outcomes (Lipton, Stewart, & Sawyer, 2000). (Grade B, Level 1+)
C - Symptomatic medications should be administered early in an acute attack when pain is only mild to moderate (Gladstone & Dodick, 2003; Evers & Frese, 2005; Kaniecki, 2006; Foley et al., 2005). (Grade C, Level 2+)
D - Over-the-counter paracetamol-based medication should be tried as first-line acute treatment of migraine. (Grade D, Level 2+)
D - If paracetamol is ineffective in an individual patient, non-steroidal anti-inflammatory drugs should be tried. If non-steroidal anti-inflammatory drugs are ineffective or contraindicated, migraine-specific agents (triptans, ergotamine) should be tried. (Grade D, Level 4)
D - A non-oral route of administration should be chosen for patients who present with early nausea or vomiting. (Grade D, Level 4)
D - In some patients, concomitant treatment with an antiemetic and oral migraine medication may be appropriate. (Grade D, Level 4)
D - The danger of medication-overuse headache developing with excessive use of symptomatic migraine medication should be emphasized to the patient ("Classification and diagnostic criteria," 1988; Silberstein & Lipton, 1997). (Grade D, Level 4)
Pharmacological Treatment of Acute Attacks
A, B & C - Recommended dosage and frequency of various drugs used in the treatment of acute migraine episode:
Drugs |
Dosage and Frequency |
Grade and Level |
Non-steroidal anti-inflammatory drugs |
Acetylsalicylic
(Boureau et al., 1994; Tfelt-Hansen & Olesen, 1984)
|
600-800 mg 8 hrly/prn |
Grade B, Level 1+ |
Ibuprofen
(Havanka-Kanniainen, 1989; Kloster, Nestvold, & Vilming, 1992
|
400-800 mg 8 hrly/prn |
Grade A, Level 1++ |
Naproxen sodium
(Johnson, Ratcliffe, & Wilkinson, 1985; Sargent et al., 1988)
|
275-550 mg 6 hrly/prn |
Grade A, Level 1++ |
Diclofenac
(Del Bene et al., 1987)
|
I/M 30 mg 6 hrly, up to 2 doses/day |
Grade B, Level 1+ |
Diclofenac-K
(Dahlöf & Björkman, 1993)
|
50-100 mg stat |
Grade B, Level 1+ |
Antiemetics |
Metoclopramide
(Coppola, Yealy, & Leibold, 1995; Ellis et al., 1993; Tek et al., 1990; Tfelt-Hansen et al.,1980)
|
I/V 10 mg stat |
Grade B, Level 1+ |
Prochlorperazine
(Coppola, Yealy, & Leibold, 1995; Jones, Pack, & Chun, 1996)
|
I/M 10-12.5 mg stat |
Grade B, Level 1+ |
*Domperidone
(Amery & Waelkens, 1983; Waelkens, 1984)
|
20-40 mg |
Grade C, Level 2+ |
Nonselective 5-hydroxytryptamine receptor agonists |
Ergotamine
(Kangasniemi & Kaaja, 1992; Ostfeld, 1961; Waters, 1970; Friedman, DiSerio, & Hwang, 1989; Ryan, 1970; Sargent et al., 1988)
|
1-2 mg 1 hrly (up to total of 3 doses) + Caffeine |
Grade A, Level 1++ |
Selective 5-hydroxytryptamine receptor agonists |
Sumatriptan
(Akpunonu et al., 1995; Bates et al., 1994; Bousser, d'Allens, & Richard, 1993; Cady et al., 1993; Cady et al., 1991; Facchinetti et al., 1995; Cady et al., 1998; Gross et al., 1994; Henry & d'Allens, 1993; Jensen et al., 1995; Mathew et al., 1992; Russell et al., 1994; "Treatment of migraine," 1991; "Self-treatment," 1991)
|
S/C 6 mg stat
Oral 50-100 mg 2 hrly (up to 2 doses/day) (Cutler et al., 1995; Jackson, 1996; Myllylä et al., 1998; Nappi et al., 1994; "Sumatriptan," 1991; "Evaluation," 1991; Pfaffenrath et al., 1998; Pini et al., 1995; Sargent et al., 1995; Tfelt-Hansen et al., 1995; Cutler et al., 1996)
|
Grade A, Level 1++ |
Zolmitriptan
(Rapoport et al., 1997; Solomon et al., 1997; Visser et al., 1996)
|
2.5 mg 2 hrly (up to 2 doses/day) |
Grade A, Level 1++ |
Naratriptan
(Klassen et al., 1997; Mathew et al., 1997)
|
2.5 mg 4 hrly (up to 2 doses/day) |
Grade A, Level 1++ |
Eletriptan
(Diener, 2005; Takiya, Piccininni, & Kamath, 2006; Stark et al., 2002; Diener et al., 2002)
|
40-80 mg 2 hrly (up to 2 doses/day) |
Grade A, Level 1++ |
* Domperidone can be used as an adjunct to oral treatment when nausea is prominent.
Abbreviations: hrly = hourly; prn = as needed; stat = immediately; I/M = intramuscular; I/V = intravenous; S/C = subcutaneous
Prophylaxis
D - The following principles will enhance the success of prophylactic treatment
- Medication use:
- Therapy may need to be started with the lowest effective dose, with a gradual upward titration of the dose until clinical benefits are achieved in the absence of adverse events or until limited by adverse events.
- Give each treatment an adequate trial of at least 1 month to establish benefit or lack thereof.
- Use of a long-acting formulation may improve compliance.
- Patient education:
- Maximize compliance. Discuss with the patient the rationale for a particular treatment, when and how to use it, and what adverse events are likely.
- Address patient expectations. Discuss with the patient the expected benefits of therapy and how long it will take to achieve them.
- Create a formal management plan
- Evaluation:
- Patients with difficult headaches should be monitored with headache diaries. Diaries should be user-friendly and should measure attack frequency, severity, duration, disability, response to type of treatment, and adverse effects of medication.
(Grade D, Level 4)
D - Daily migraine prophylactic treatment should be considered if 2 or more attacks a month occur (Tfelt-Hansen & Welch, 1993). (Grade D, Level 4)
D - The decision to start or withhold pharmacological prophylaxis should be individualized to the patient with migraine. Apart from the frequency of attacks, attack severity, failure or intolerance of acute treatments, concurrent medical conditions and prolonged aura may be relevant considerations (Silberstein & Lipton, 1997). (Grade D, Level 4)
GPP - If benefit is seen with the migraine prophylactic treatment, a course of medication ideally lasting at least 6 months should be given. (GPP)
A & B - Recommended dosage and frequency of various drugs used in the prevention of recurrent migraine episodes:
Drugs |
Dosage and Frequency |
Grade and Level |
Beta blockers |
Atenolol
(Forssman, Lindblad, & Zbornikova, 1983; Johannsson et al., 1987)
|
50-100 mg om |
Grade A, Level 1++ |
Propranolol
(Ahuja & Verma, 1985; Børgesen, Nielsen, & Møller, 1974; Dahlöf, 1987; Forssman et al., 1976; Johnson, Hornabrook, & Lambie, 1986; Mikkelsen, Pedersen, & Christiansen, 1986; Pita et al., 1977; Pradalier et al.,1989; Sargent et al.,1985; Stensrud & Sjaastad, 1976; Tfelt-Hansen et al., 1984; Widerøe & Vigander, 1974) |
40-240 mg/day |
Grade A, Level 1++ |
Metoprolol
(Andersson et al., 1983; Kangasniemi et al., 1987; Steiner et al., 1988; Gerber et al., 1991; Kangasniemi & Hedman. 1984; Olsson et al., 1984)
|
50-300 mg/day |
Grade A, Level 1++ |
Bisoprolol
(van de Ven, Franke, & Koehler, 1997)
|
5 mg/day |
Grade B, Level 1+ |
Calcium channel blockers |
Flunarizine
(al Deeb et al., 1992; Diamond & Freitag, 1993; Louis, 1981; Mendenopoulos et al., 1985; Pini et al., 1985; Sørensen, Hansen, & Olesen, 1986; Thomas, Behari, & Ahuja, 1991; Frenken & Nuijten, 1984)
|
5-10 mg on |
Grade A, Level 1++ |
Verapamil
(Solomon, 1986; Markley, Cheronis, & Piepho, 1984; Solomon, Steel, & Spaccavento, 1983)
|
240 mg om |
Grade A, Level 1++ |
Serotonin receptor antagonists |
Pizotifen
(Bellavance & Meloche, 1990; Ryan, 1968; Arthur & Hornabrook, 1971; Carroll & Maclay, 1975; Hughes & Foster, 1971; Krakowski & Engisch, 1973; Lance & Anthony, 1968; Lawrence, Hossain, & Littlestone, 1977; Osterman, 1977; Ryan, 1971; Sjaastad & Stensrud, 1969; Symon & Russell, 1995)
|
0.5-2 mg tds |
Grade A, Level 1++ |
Antidepressants |
Amitriptyline
(Couch & Hassanein, 1976; Couch & Hassanein, 1979; Gomersall & Stuart, 1973; Ziegler et al., 1987)
|
10-150 mg on |
Grade A, Level 1++ |
Fluoxetine
(Adly, Straumanis, & Chesson, 1992; Steiner et al., 1998)
|
10-40 mg om |
Grade B, Level 1+ |
Venlafaxine
(Ozyalcin et al., 2005; Adelman et al., 2000)
|
75-150 mg/day |
Grade B, Level 1+ |
Anticonvulsants |
Sodium Valproate/Valproic acid
(Klapper, 1997; Mathew et al., 1995; Hering & Kuritzky, 1992; Jensen, Brinck, & Olesen, 1994)
|
500-1500 mg/day |
Grade A, Level 1++ |
Topiramate
(Bussone et al., 2005; D'Amico et al., 2005; Mei et al., 2004; Diener et al 2004; Silberstein et al., 2004; Brandes et al., 2004; Storey et al., 2001)
|
50-200 mg/day |
Grade A, Level 1++ |
Gabapentin
(Mathew et al., 2001; Di Trapani et al., 2000)
|
1200 mg/day |
Grade B, Level 1+ |
Non-steroidal anti-inflammatory |
Naproxen sodium
(Bellavance & Meloche, 1990; Lindegaard, Övrelid, & Sjaastad, 1980; Sances et al., 1990; Szekely et al., 1989; Welch, Ellis, & Keenan, 1985; Ziegler & Ellis, 1985)
|
550 mg bd |
Grade A, Level 1++ |
Angiotensin blockers |
Candesartan
(Tronvik et al., 2003)
|
16 mg/day |
Grade B, Level 1+ |
Lisinopril
(Schrader et al., 2001)
|
10-20 mg/day |
Grade B, Level 1+ |
Others |
Feverfew
(Palevitch, Earon, & Carasso, 1997; De Weerdt, Bootsma, & Hendriks, 1996; Pfaffenrath et al., 2002; Murphy, Heptinstall, & Mitchell, 1988)
|
50-82 mg/day |
Grade B, Level 1+ |
Magnesium
(Peikert, Wilimzig, & Köhne-Volland, 1996; Pfaffenrath et al., 1996; Facchinetti et al., 1991)
|
400-600 mg/day |
Grade B, Level 1+ |
Riboflavin
(Schoenen, Jacquy, & Lenaerts, 1998; Schoenen, Lenaerts, & Bastings, 1994; Maizels, Blumenfeld, & Burchette, 2004)
|
200 mg bd |
Grade B, Level 1+ |
Coenzyme Q10
(Sandor et al., 2005)
|
300 mg/day |
Grade B, Level 1+ |
Botulinum toxin A
(Chilson & Brown, 2005; Gobel, 2004; Silberstein et al., 2000; Evers et al., 2002)
|
Botox 25U |
Grade A, Level 1+ |
Butterbur (Petadolex)
(Diener, Rahlfs, & Danesch, 2004; Grossmann &, Schmidramsl, 2000; Lipton et al., 2004)
|
50 mg-150/day |
Grade B, Level 1+ |
Abbreviations: bd = twice a day; om = every morning; on = every night; tds = three times a day
A - Homeopathic treatment should not be used for migraine prophylaxis (Whitmarsh, Coleston-Shields, & Steiner, 1997; Straumsheim et al., 2000). (Grade A, Level 1+)
Migraine in Pregnancy and Lactation
D - Non-pharmacological management of migraine is preferred in pregnancy (Silberstein, 2000). (Grade D, Level 2)
D - Biofeedback, relaxation training, and physical therapy may be tried in the treatment of migraine in pregnancy (Hickling, Silverman, & Loos, 1990; Marcus, Scharff, & Turk, 1995). (Grade D, Level 3)
The U.S. Food and Drug Administration classify drugs according to the foetal risk associated with their use.
Category A - safety established using human studies
Category B - presumed safety based on animal studies
Category C - adverse effects in animal studies, human effects unknown
Category D - known foetal risks
Category X - high foetal risks
GPP - Drugs with a Category A or Category B rating should be used to manage migraine in pregnancy. Category C drugs should be considered after careful consideration of potential risks and benefits. Category D or Category X drugs should be avoided. (GPP)
GPP - Therapy for migraine in women who are pregnant or lactating should be approached cautiously and initiated only with the consent of the patient after informed evaluation of the risks. (GPP)
D - Paracetamol (Category B) is the drug of choice for treatment of acute migraine in pregnancy. Codeine which is category B drug becomes category D in 3rd trimester. Therefore, codeine is not recommended in the 3rd trimester (Aube, 1999). (Grade D, Level 4)
B - Naproxen, ibuprofen, and aspirin which are category B drugs become category D after 32 weeks of gestation. Hence, their use should be avoided after 32 weeks of gestation because of the risk of maternal or foetal bleeding and premature closure of the foetal ductus arteriosis. (Grade B, Level 2+)
D - Intravenous magnesium sulphate 1g over one to three minutes up to a maximum of three IV injections given a week apart may be given to patients who experience frequent disabling headaches during pregnancy (Demirkaya, et al., 2001). (Grade D, Level 3)
D - Intravenous prochlorperazine may be considered if extreme nausea and vomiting are present during migraine in pregnancy (Rozen, 2003). (Grade D, Level 3)
D - Fluoxetine, metoprolol and magnesium (category B) can be used as prophylactic treatment of migraine (Bousser & Massiou, 1993; Pfaffenrath & Rehm. 1998; Gendolla & Evers, 2004). (Grade D, Level 4)
B - Valproic acid and its derivatives can be teratogenic and should be avoided. Lisinopril and candesartan should not be used during pregnancy (Silberstein, 2004; Marcus, 2003). (Grade B, Level 2+)
D - Acetaminophen, narcotics, diclofenac, ibuprofen, prochlorperazine, beta-blockers, and moderate caffeine may be considered for treating migraine in lactating women (American Academy of Pediatrics Committee on Drugs, 1994). (Grade D, Level 4)
Menstrual Migraine
A & B - Recommended dosage and frequency of various drugs used in the prophylaxis of menstrual migraine (where 90% of the headaches occur within the 48 hours prior to menses).
Drugs |
Dosage and Frequency |
Grade and Level |
Oestrogen patches/gel*
(Macgregor & Hackshaw, 2002; Dennerstein et al., 1988; de Lignières et al.,1986) |
50 micrograms - 1.5 mg/day |
Grade A, Level 1++ |
Naproxen
(Sances et al., 1990)
|
275-550 mg bd |
Grade B, Level 1+ |
Naratriptan
(Newman et al., 2001)
|
2.5 mg bd |
Grade B, Level 1+ |
Magnesium
(Facchinetti et al., 1991)
|
360 mg of magnesium pyrrolidone carboxylic acid |
Grade B, Level 1+ |
* Migraine without aura is not an established contraindication to contraceptive use.
D - Estrogen-containing oral contraceptives should be avoided in women with migraine with focal neurologic signs (Benson & Rebar, 1986). (Grade D, Level 4)
Migraine in Children Less than 18 Years Old
A - Acute migraine attacks in a child should be treated with paracetamol or ibuprofen. Oral triptans are not superior to placebo in paediatric migraine (Damen et al., 2005; Lewis, Scott, & Rendin, 2002; Lewis et al., 2005). (Grade A, Level 1++)
A - Propranolol (60-120 mg/day) or flunarizine (5-10 mg/day) should be considered if migraine prophylaxis is required in a child (Victor & Ryan, 2003; Lewis et al., 2004). (Grade A, Level 1+)
B - Amitriptyline or cyproheptadine may also be used for childhood migraine prophylaxis (Victor & Ryan, 2003; Lewis et al., 2004). (Grade B, Level 2++)
D - Valproate, topiramate, and levetiracetam may also be considered for childhood migraine prophylaxis on the basis of limited data (Pakalnis et al., 2001; Serdaroglu et al., 2002; Hershey et al., 2002; Campistol et al., 2005; Miller, 2004). (Grade D, Level 3)
Headaches - Psychiatric and Psychological Aspects
Psychological Management
D - Patients with migraines and tension headaches should be evaluated for psychiatric co-morbidities such as anxiety or depression (Rowan & Andrasik, 1996). (Grade D, Level 4)
D - If hyperventilation accompanies tension headache and migraines, specific explanation and advice regarding anxiety disorder should be provided (Silberstein & Rosenberg, 2000). (Grade D, Level 3)
Biofeedback
C - Adjunctive psychological interventions should be considered in patients with headaches that are difficult to manage. (Grade C, Level 2+)
Secondary Headaches
Referral of Patients with Suspected Secondary Headaches
GPP - All patients with suspected secondary headaches should be referred to a specialist.
A referral is indicated if the following features are present:
- Systemic symptoms such as fever or change in mental state
- Neurological deficits
- Sudden onset or maximum severity at onset
- The first severe or worst headache in an individual's life
- New persistent or progressively worsening headaches
- Changed character in the normal established headache pattern
- A new headache in middle age or later
- Headache precipitated by coughing, sneezing, standing, bending forwards or recumbency
(GPP)
Headache Attributed to Chronic Subdural Haematoma
D - Chronic subdural haematoma should always be considered in an elderly patient with a progressive headache, particularly if there is some cognitive impairment or focal signs. (Grade D, Level 3)
Investigations for Headaches
Neuroimaging
C - Neuroimaging should be considered in patients with nonacute headache and an unexplained abnormal finding on neurological examination. (Grade C, Level 2+)
C - Neuroimaging is not warranted for patients diagnosed with migraines and having a normal neurological examination (Igarashi et al., 1991; Cuetter & Aita, 1983; Cull, 1995; De Benedittis et al., 1995; Hungerford, du Boulay, & Zilkha, 1976; Kuhn & Shekar, 1990; Osborn, Alder, & Mitchell, 1991; Robbins & Friedman, 1992; Sargent et al, 1979). (Grade C, Level 2+)
Skull X-rays
D - Skull X-rays are not recommended in the evaluation of headaches. (Grade D, Level 3)
Lumbar Punctures
D - Lumbar punctures are not recommended in the routine evaluation of headaches. (Grade D, Level 3)
GPP - Neuroimaging is mandatory before lumbar puncture if a neurological deficit is present or increased intracranial pressure is suspected. (GPP)
Medication Overuse Headaches
Management
C - For ergotamine-induced medication overuse headache, naproxen 500 mg twice daily may be used for pain reduction during the withdrawal period (Matthew, 1987). (Grade C, Level 2+)
GPP - During withdrawal, prophylactic treatment of the primary headache should be started concurrently. (GPP)
GPP - Strictly limited doses of anti-emetic medication and analgesics may be used to treat break-through attacks. (GPP)
C - Prednisolone 60 mg/day for 2 days, 40 mg/day for next 2 days and 20 mg/day for last 2 days and ranitidine 200 mg/day during the 6 days should be taken to alleviate headache intensity (Diener & Dahlöf, 1999). (Grade C, Level 2+)
D - Highly motivated patients who are not using barbiturates and tranquilizers (benzodiazepines) may be treated as outpatients. Patients who overuse drugs containing codeine, barbiturates, or tranquilizers, those who are depressed or who have failed previously to withdraw as outpatients, would be candidates for hospitalized management (Fritsche & Diener, 2002). (Grade D, Level 4)
Prevention
GPP - The best strategy to reduce the prevalence of medication overuse headache is to prevent the development of medication overuse headache in the first place. Doctors should set maximal monthly dosages for headache abortive drugs. Maximum doses and frequencies of types of medications that cause medication overuse headache:
Medication |
Maximum Dose |
Simple analgesics (aspirin and paracetamol) |
Intake <10 days per month |
Combination analgesics (caffeine or barbiturate-containing drugs) |
<3 tablets/day |
Opioids |
<1 tablet /day |
Ergotamine (oral) |
Max 4 mg/attack and <20 mg/month |
Serotonin 5-HT1B/1D receptor agonists ("triptans") |
<2 doses/attack and <6 doses per month |
(GPP)
D - Patients should be educated on the risk of medication overuse headache (Fritsche & Diener, 2002). (Grade D, Level 4)
D - A headache diary is a useful tool for patients and their doctors to monitor the frequency of headaches and medication usage (Fritsche & Diener, 2002). (Grade D, Level 4)
Use of Acupuncture in the Management of Migraine and Tension Headache
Evidence for Efficacy
A - Acupuncture may be considered for headache prophylactic treatment (Melchart et al., 2001). (Grade A, Level 1++)
Cautions
GPP - Caution should be exercised in using acupuncture in the following conditions:
- Patients with severe bleeding disorders or on anti-coagulant treatment – a contraindication for needle acupuncture
- Pregnancy
- Presence of a cardiac pacemaker – a contraindication for electrical stimulation
- Indwelling needles should not be used in patients at risk from bacteremia, such as asplenic patients or those who may become neutropenic
(GPP)
Definitions:
Grades of Recommendation
Grade A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1+ + and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
Grade B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1+ + or 1+
Grade C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2+ +
Grade D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points (GPP): Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level 1++: High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias.
Level 1+: Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.
Level 1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
Level 2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
Level 2+: Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
Level 2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
Level 3: Non-analytic studies, e.g., case reports, case series
Level 4: Expert opinion