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Diagnosis and Management of Headaches: NICE CG150

Posted in Guidelines on 29th May 2013


Mark Baker

Professor Mark Baker is the Director of the Centre for Clinical Practice (CCP) and is responsible for designing and operating methods and systems to produce clinical guidelines for the NHS. These products integrate, where appropriate with those produced by the health technology evaluation and public health excellence centres, to form comprehensive prevention and treatment recommendations for practitioners in the NHS and the wider public health community. CCP is also responsible for the work of the Medicines and Prescribing Centre including summaries of evidence on new medicines and unlicensed and off-label medicines and the management of the contract for the>

Correspondence to:
Professor M Baker, National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BD, UK.

In 2012, the UK’s National Institute for Health and Care Excellence (NICE) published its first clinical guideline for the National Health Service (NHS) on the diagnosis and management of headache in adults and young people.

The guideline advises on the care for the most common primary headaches – tension-type headache,migraine and cluster headache – as well as medication overuse, which has been estimated to affect 1-2% of the population.

NICE has issued its guideline to support clinicians, such as neurologists and general practitioners, in their clinical decision-making by outlining the assessment criteria, diagnostic tools and treatments, which are proven to be most clinically and cost effective. It is hoped that this will standardise care of headaches across the NHS so that people with the condition receive the best treatments and support possible, in a timely and coordinated manner.

Key recommendations

This guideline recommends some drugs for indica- tions for which they do not have UK marketing authorisations for (at the date of publication – September 2012), if there is good evidence to support their use in this way. To view NICE’s full recommendations, details about off label use and evidence-base, download the clinical guideline from the NICE website.

All headache disorders

• 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 explana- tion of the diagnosis and reassurance that other pathology has been excluded and

– the options for management and o recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers

Migraine with or without aura

Acute treatment

• Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and parac- etamol, 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 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 metoclo- pramide or prochlorperazine and

– consider adding a non-oral NSAID or triptan if these have not been tried. Prophylactic treatment

• 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.

Cluster headache

Acute treatment

• 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.


The NICE clinical guideline offers practical evidence-based advice for nurses and other health- care professionals on how to diagnosis and manage headaches.

Implementation of the guideline will improve the assessment and management of headaches and enable patients to obtain appropriate treatment sooner.

To download the NICE clinical guideline and to access support tools or information to give to your patients, please visit: