Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Headache disorders are generally classified as either primary or secondary, and these classifications are further divided into specific headache types. Primary headache disorders are not associated with an underlying pathology and include migraine, tension-type, and cluster headache. Secondary headache disorders are attributed to an underlying pathological condition and include any head pain of infectious, neoplastic, vascular, or drug-induced origin.
The individual patient's history is of prime importance in the evaluation of headache. The aim of the history is to classify the headache type(s) and screen for secondary headache using "red flag" features (see "Secondary Headache" below). An inadequate history is the probable cause of most misdiagnosis of the headache type (see Annex 4 of the original guideline document ["Availability of Companion Documents" field in this summary] for a list of questions to help with taking a patient's headache history from the British Association for the Study of Headache.).
Symptoms and Signs
Primary Headache
Migraine
Distinguishing features of a migraine (Not all have to be present to make the diagnosis):
- Episodic severe headache that causes disability
- Nausea
- Sensitivity to light during headache
- Sensitivity to light between attacks
- Sensitivity to noise
- Typical aura (in 15–33% of patients with migraine)
- Exacerbation by physical activity
- Positive family history of migraine
C - Patients who present with a pattern of recurrent episodes of severe disabling headache associated with nausea and sensitivity to light, and who have a normal neurological examination, should be considered to have migraine.
Tension-Type Headache
C - A diagnosis of tension-type headache should be considered in a patient presenting with bilateral headache that is non-disabling where there is a normal neurological examination.
Trigeminal Autonomic Cephalalgias
D - When a patient presents with frequent, brief, unilateral headaches with autonomic features a trigeminal autonomic cephalalgia should be considered.
D - Patients with a new suspected trigeminal autonomic cephalalgia should be referred for specialist assessment.
Hemicrania Continua
D - When a patient presents with chronic daily headache which is strictly unilateral, hemicrania continua should be considered.
D - Patients with a new suspected hemicrania continua should be referred for specialist assessment.
Secondary Headache
Secondary headache (i.e. headache caused by another condition) should be considered in patients presenting with new onset headache or headache that differs from their usual headache. Observational studies have highlighted the following warning signs or red flags for potential secondary headache which requires further investigation:
Red flag features:
- New onset or change in headache in patients who are aged over 50
- Thunderclap: rapid time to peak headache intensity (seconds to 5 minutes)
- Focal neurological symptoms (e.g., limb weakness, aura <5 min or >1 hr)
- Non-focal neurological symptoms (e.g., Cognitive disturbance)
- Change in headache frequency, characteristics or associated symptoms
- Abnormal neurological examination
- Headache that changes with posture
- Headache wakening the patient up (note well (nb): migraine is the most frequent cause of morning headache)
- Headache precipitated by physical exertion or valsalva manoeuvre (e.g., coughing, laughing, straining)
- Patients with risk factors for cerebral venous sinus thrombosis
- Jaw claudication or visual disturbance
- Neck stiffness
- Fever
- New onset headache in a patient with a history of human immunodeficiency virus (HIV) infection
- New onset headache in a patient with a history of cancer
D - Patients who present with headache and red flag features of potential secondary headache should be referred to an appropriate specialist for further assessment.
D - Patients presenting with headache for the first time or with headache that differs from their usual headache should have a clinical examination, a neurological examination including fundoscopy, and blood pressure measurement.
Thunderclap Headache
D - Patients with a first presentation of thunderclap headache should be referred immediately to hospital for same day specialist assessment.
Cervicogenic Headache
D - Neck examination should be carried out in all patients presenting with headache including assessment of:
- Neck posture
- Range of movement
- Muscle tone
- Muscle tenderness
Raised Intracranial Pressure
D - Patients with headache and features suggestive of raised intracranial pressure should be referred urgently for specialist assessment.
D - Patients with headache and features suggestive of central nervous system (CNS) infection should be referred immediately for same day specialist assessment.
Intracranial Hypotension (Spontaneous or Iatrogenic)
D - Intracranial hypotension should be considered in all patients with headache developing or worsening after assuming an upright posture.
Giant Cell (Temporal) Arteritis
D - Giant cell arteritis should be considered in any patient over the age of 50 presenting with a new headache or change in headache.
Angle Closure Glaucoma
D - Angle closure glaucoma should be considered in a patient with headache associated with a red eye, halos or unilateral visual symptoms.
Assessment Tools
D - Practitioners should consider using headache diaries and appropriate assessment questionnaires to support the diagnosis and management of headache (See Table 2 of the original guideline document for a summary of a number of tools readily available via the internet, such as Headache Impact Test [HIT/HIT 6], Migraine Disability Assessment [MIDAS] and an assessment of their impact.)
Investigations
Neuroimaging
D - Neuroimaging is not indicated in patients with a clear history of migraine, without red flag features for potential secondary headache, and a normal neurological examination.
D - Clinicians requesting neuroimaging should be aware that both magnetic resonance imaging (MRI) and computerised tomography (CT) can identify incidental neurological abnormalities which may result in patient anxiety as well as practical and ethical dilemmas with regard to management.
D - Brain CT should be performed in patients with headache who have unexplained abnormal neurological signs, unless the clinical history suggests MRI is indicated.
Computerised Tomography (CT) and Thunderclap Headache
D - In patients with thunderclap headache, unenhanced CT of the brain should be performed as soon as possible and preferably within 12 hours of onset.
Magnetic Resonance Imaging
D - Brain MRI should be considered in patients with cluster headache, paroxysmal hemicrania or short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).
D - Brain MRI should be carried out in patients presenting with headache which is precipitated, rather than aggravated, by cough.
Lumbar Puncture in Subarachnoid Haemorrhage
C - Patients with thunderclap headache and a normal CT should have a lumbar puncture.
D - In patients who require a lumbar puncture for thunderclap headache, oxyhaemoglobin and bilirubin should be included in cerebrospinal fluid analysis.
Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP) and Plasma Viscosity in Giant Cell Arteritis
D - ESR and/or CRP (but preferably a combination of these diagnostic tests to maximise sensitivity and specificity) should be measured in patients with suspected giant cell arteritis.
Migraine
Acute Treatment
Non-steroidal Anti-Inflammatory Drugs (including Aspirin) and Paracetamol
A - Aspirin 900 mg is recommended for acute treatment in patients with all severities of migraine.
A - Ibuprofen 400 mg is recommended for acute treatment in patients with migraine.
B - Paracetamol 1,000 mg is recommended as acute treatment for mild to moderate migraine.
Triptans
A - Oral triptans are recommended for acute treatment in patients with all severities of migraine if previous attacks have not been controlled using simple analgesics.
A - Almotriptan 12.5 mg, eletriptan 40-80 mg or rizatriptan 10 mg, are the preferred oral triptans for acute migraine.
B - If a patient does not respond to one triptan an alternative triptan should be offered.
D - Triptans should be taken at, or soon after, the onset of the headache phase of a migraine attack.
C - A combination of sumatriptan 50-100 mg and naproxen sodium 500 mg may be helpful in acute migraine particularly in prolonged attacks which are associated with recurrence.
Anti-Emetics
D - Oral and rectal anti-emetics can be used in patients with acute migraine attacks to reduce symptoms of nausea and vomiting and to promote gastric emptying.
B - A combination of aspirin and metoclopramide can be used for the treatment of patients with acute migraine attacks.
B - Fixed analgesic/anti-emetic combinations can be used for the treatment of patients with acute migraine attacks.
B - Intravenous (IV) metoclopramide can be used in the acute management of patients with migraine.
Ergotamine
A - Ergotamine is not recommended for patients with acute migraine.
Other Therapies
D - Opioid analgesics should not be routinely used for the treatment of patients with acute migraine due to the potential for development of medication overuse headache.
Pharmacological Prophylaxis
Beta Blockers
A - Propranolol 80-240 mg per day is recommended as first line therapy for prophylaxis in patients with migraine.
D - Timolol, atenolol, nadolol and metoprolol can be used as alternatives to propranolol as prophylaxis in patients with migraine.
Antiepileptics
A - In patients with episodic migraine and chronic migraine topiramate 50-200 mg per day is recommended to reduce headache frequency and severity.
A - In patients with episodic migraine sodium valproate 800-1,500 mg per day is recommended to reduce headache frequency and severity.
C - Patients with episodic and chronic migraine can be treated with gabapentin 1,200 -2,400 mg per day to reduce headache frequency.
Antidepressants
B - Selective serotonin reuptake inhibitors (SSRIs) are not recommended in the prophylaxis of migraine.
B - Amitriptyline 25-150 mg per day is recommended for patients requiring prophylaxis of migraine.
B - Venlafaxine 75-150 mg per day is an effective alternative to tricyclic antidepressants for prophylaxis of migraine.
Other Therapies
A - Botulinum toxin A is not recommended for the prophylactic treatment of migraine.
Tension-Type Headache
Acute Treatment
A - Aspirin and paracetamol are recommended for acute treatment in patients with tension-type headache.
Pharmacological Prophylaxis
Antidepressants
A - Tricyclic antidepressants, particularly amitriptyline, 25-150 mg per day, are recommended as the agents of choice where prophylactic treatment is being considered in a patient with chronic tension-type headache.
Other Therapies
B - Botulinum toxin A is not recommended for the preventive treatment of chronic tension-type headache.
Trigeminal Autonomic Cephalalgias
Acute Treatment of Cluster Headache
Triptans
A - Subcutaneous injection of 6 mg sumatriptan is recommended as the first choice treatment for the relief of acute attacks of cluster headache.
A - Nasal sumatriptan or zolmitriptan is recommended for treatment of acute attacks of cluster headache in patients who cannot tolerate subcutaneous sumatriptan.
Pharmacological Prophylaxis
Calcium Channel Blockers
B - Verapamil 240-960 mg is recommended for the prophylaxis of cluster headache.
Treatment of Paroxysmal Hemicrania, Hemicrania Continua, and SUNCT
D - Indomethacin up to 225 mg is recommended for the prophylaxis of paroxysmal hemicrania and hemicrania continua.
Medication Overuse Headache
Definitions and Assessment
D - Medication overuse headache must be excluded in all patients with chronic daily headache (headache ≥15 days / month for >3 months).
D - Clinicians should be aware that patients using any acute or symptomatic headache treatment are at risk of medication overuse headache. Patients with migraine, frequent headache and those using opioid-containing medications or overusing triptans are at most risk.
C - When diagnosing medication overuse headache, psychiatric comorbidity and dependence behaviour should be considered.
C - Patients with medication overuse headache who have psychiatric comorbidity or dependence behaviour should have these conditions treated independently. Referral to a psychiatrist or a clinical psychologist should be considered.
Treatment
C - Patients with medication overuse headache caused by simple analgesics or triptans should be advised to abruptly withdraw the overused medication. In the majority of patients this can be as an outpatient with structured advice.
D - Patients with medication overuse headache caused by opioids and opioid-containing analgesics should be considered for gradual withdrawal of the overused medications.
D - If frequent headache persists after symptomatic medications have been withdrawn, prophylactic agents may be effective and should be considered.
C - In patients with medication overuse headache, topiramate may be considered in order to reduce the total number of headache days.
Pregnancy, Contraception, Menstruation and the Menopause
Oral Contraception
B - Women with migraine with aura should not use a combined oral contraceptive pill.
D - Patients with migraine without aura who are over the age of 35 should not use a combined oral contraceptive pill.
Menstruation
Simple Analgesics
A - Patients with acute menstrual migraine can be treated with mefenamic acid or a combination of aspirin, paracetamol and caffeine.
Triptans
A - Sumatriptan, zolmitriptan, naratriptan and rizatriptan are recommended for the acute treatment of patients with menstrual migraine.
Prophylaxis for Menstrual Migraine
A - Frovatriptan 2.5 mg/day or naratriptan 1 mg twice daily taken two days before day one of the menstrual cycle then for a further four or five days respectively is recommended for the prophylaxis of menstrual migraine.
Menopause
D - Hormone replacement therapy (HRT) can be prescribed to menopausal and perimenopausal women with migraine.
D - If a patient taking HRT experiences worsening migraine, HRT should be considered as a possible cause.
Lifestyle Factors
Stress Management
B - Stress management should be considered as part of a combined therapies programme to help patients reduce the frequency and severity of migraine headaches.
Physical Therapies
Manual Therapy
B - Spinal manipulation therapy should be considered in patients with cervicogenic headache.
Acupuncture
B - Acupuncture should be considered for preventive management in patients with migraine.
Oral Rehabilitation
B - Occlusal adjustment is not recommended for treatment of patients with headache associated with temporomandibular disorders.
Complementary Therapies
Minerals, Vitamins, and Herbs
A - Feverfew is not recommended for preventive treatment of patients with migraine.
B - Intravenous magnesium is not recommended as treatment in patients with acute migraine attack.
Definitions:
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review, or randomized controlled trial (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
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+
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++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
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
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
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
