• Singapore Ministry of Health. Diagnosis and management of headache. Singapore: Singapore Ministry of Health; 2007 Sep. 104 p. [374 references]

This is the current release of the guideline.

This guideline updates a previous version: Singapore Ministry of Health. Diagnosis and management of headache. Singapore: Singapore Ministry of Health; 2000 Nov. 25 p. [15 references]

The workgroup advises that these guidelines be scheduled for review 5 years after publication, or if new evidence appears that requires substantive changes to the recommendations.

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)

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:

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:

* 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

1. Medication use:
   1. 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.
   2. Give each treatment an adequate trial of at least 1 month to establish benefit or lack thereof.
   3. Use of a long-acting formulation may improve compliance.

2. Patient education:
   1. Maximize compliance. Discuss with the patient the rationale for a particular treatment, when and how to use it, and what adverse events are likely.
   2. Address patient expectations. Discuss with the patient the expected benefits of therapy and how long it will take to achieve them.
   3. Create a formal management plan

3. Evaluation:
   1. 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:

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).

* 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:

1. Systemic symptoms such as fever or change in mental state
2. Neurological deficits
3. Sudden onset or maximum severity at onset
4. The first severe or worst headache in an individual's life
5. New persistent or progressively worsening headaches
6. Changed character in the normal established headache pattern
7. A new headache in middle age or later
8. 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:

(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

None available

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Singapore Ministry of Health. Diagnosis and management of headache. Singapore: Singapore Ministry of Health; 2007 Sep. 104 p. [374 references]

Not applicable: The guideline was not adapted from another source.

2000 Nov (revised 2007 Sep)

National Committee on Neuroscience (Singapore) - National Government Agency [Non-U.S.]
National Medical Research Council (Singapore Ministry of Health) - National Government Agency [Non-U.S.]
Singapore Ministry of Health - National Government Agency [Non-U.S.]

These guidelines on the diagnosis and management of headache were prepared by the Singapore National Committee on Neuroscience through its Subcommittee on Headache.

Singapore Ministry of Health

Workgroup on the Diagnosis and Management of Headache

Workgroup Members: Dr Siow Hua Chiang, Charles, Consultant Neurologist, Siow Neurology, Headache and Pain Centre, Mount Alvernia Hospital, Mount Elizabeth Hospital (Chairperson); Dr Ho King Hee, Consultant Neurologist, K H Ho Neurology & Medical Clinic; Gleneagles Medical Centre; Dr Lim Shih Hui, Senior Consultant, Dept of Neurology, NNI (SGH Campus); Dr Lee Sze Haur, Senior Consultant, Dept of Neurology, NNI (TTSH Campus); Dr Chan Yee Cheun, Consultant, Division of Neurology, NUH; Dr Ng Beng Yeong, Consultant, Dept of Behavioural Medicine, SGH; Dr Tan Ngiap Chuan, Director, SingHealth Polyclinics-Pasir Ris

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Singapore Ministry of Health. Diagnosis and management of headache. Singapore: Singapore Ministry of Health; 2000 Nov. 25 p. [15 references]

The workgroup advises that these guidelines be scheduled for review 5 years after publication, or if new evidence appears that requires substantive changes to the recommendations.

None available

This summary was completed by ECRI on October 25, 2001. The information was verified by the guideline developer on November 16, 2001. This summary was updated by ECRI on January 12, 2005 following the release of a public health advisory from the U.S. Food and Drug Administration regarding the use of some non-steroidal anti-inflammatory drug products. This summary was updated on April 15, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on October 3, 2005, following the U.S. Food and Drug Administration advisory on Paxil (paroxetine). This summary was updated by ECRI on December 12, 2005, following the U.S. Food and Drug Administration advisory on Paroxetine HCL - Paxil and generic paroxetine. This NGC summary was updated by ECRI Institute on February 13, 2008.