Headaches – NICE Guidance on a Page

Diagnosis

Evaluate:
- Worsening headache with fever
- Sudden-onset headache reaching maximum intensity within 5 minutes
- New-onset neurological deficit or cognitive dysfunction
- Change in personality
- Impaired level of consciousness
- Recent (typically within the past 3 months) head trauma
- Headache triggered by cough, valsalva or sneeze or 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
Further Investigate:
- Compromised immunity, caused, for example, by 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
Do not refer the following for neuro-imaging, but off re-assurance that other pathology excluded:

	Tension Headache	Migraine w or w/o aura	Cluster
Pain location	Bi-lateral	Unilateral or Bi-lateral	Pain location: Unilateral (around eye)
Pain quality	Pressing (non pulsating)	Pulsating	Variable sharp, boring
Pain Intensity	Moderate	Severe	Very Severe
Effect on activities	No aggravated	Aggravated by ADL	Restlessness
Other symptoms	None	Sensitive to light/sound; Aura	Red eye; swollen eyelid; Constricted pupil
Duration	Up to 0.5 hr	Up to 72 hrs	Up to 2 hrs

Migraine, one or more of Visual symptoms; Sensory symptoms; Speech disturbance
Aura: develops gradually, is reversible, last up to 1 hr
Menstrual related migraine: 2-3 days before start and > 2 episodes
Medication over-use headache: Triptans/opioids > 10 days/mth; NSAID/Paracetamol > 15 days/mth

Headache diary: record frequency, duration and monitor effectiveness of treatment
Tension: Aspirin, Paracetamol, NSAID, and up to 10 sessions of acupuncture, but no opioids
Migraine:
- Acute: Combination Triptan & NSAID or Paracetamol, or monotherapy of any of these if patient prefers (Consider nasal Triptan if 12-17 y/o); if ineffective Non oral Metoclopramide +/- Non oral NSAID
- Prophylaxis: Topiramate (AED) or Propanolol following discussion or risk / benefit, or if ineffective Gabapentin or 10 session acupuncture; Riboflavin 400 mg may be effective in some people
- Menstrual related migraine: Frovatriptan is no response from acute management
Cluster
- Acute: Oxygen (min 12 L non rebreathe) and subcut or nasal Triptan, do not offer Opioids or NSAIDs, or oral Triptans
- Prophylaxis: Consider Verapamil and gain specialist advice
Medication over-use: withdrawal, for at least 1 month and abruptly not gradually, and that will get worse before gets better, but review 4-8 wks after withdrawal

NICE Source: CG150 Headaches in over 12s: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.