Headache Guideline Cumbria
Cumbria Partnership NHS FT- Neurology Department
Headache Clinic Penrith
Primary headache disorders
Primary headache disorders are not associated with underlying pathology. Most common are migraine, tension headache and
cluster headache.
Secondary headache disorder
Headache attributed to underlying pathological condition, includes infectious, vascular, neoplastic and drug induced origin.
Tension Headache
Migraine
CHARACTERISTICS:
episodic
unilateral
pulsating
moderate to severe in intensity
associated with nausea or
vomiting and/or sensitivity to light
aura (in 15–33% of patients)
exacerbation by physical
activity
sensitivity to light between
attacks
Often positive family history of
migraine
Normal neurology assessment
no red flags
Investigation
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.
TREATMENT:
CHARACTERISTICS:
1. Lifestyle advice
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2. Acute treatment
• 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!
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 Bilateral
pressing or tight band like
no nausea
not aggravated by physical activity
may be pericranial tenderness, sensitivity to light or noise.
TREATMENT:
1. Lifestyle advice
2. Acute treatment
Aspirin 900 mg or NSAID Ibuprofen 400 mg or Paracetamol 1,000
mg is recommended for mild to moderate migraine.
Oral triptans in patients with all severities of migraine if simple
analgesics did not help previously. Should be taken at the onset of
the headache.
A combination of Sumatriptan 50-100 mg and Naproxen 250 - 500
mg may be helpful in acute migraine, particularly in prolonged
attacks which are associated with recurrence.
Oral and rectal anti-emetics can be used in patients with acute
migraine attacks to reduce symptoms of nausea and vomiting
Suppository, nasal spray or injections are preferred route of
treatment administration for the vomiting patient.
Aspirin, Paracetamol and NSAID are recommended for acute
treatment in patients with tension-type headache.
3. Prophylaxis
Tricyclic antidepressants (particularly Amitriptyline 25 – 75 mg)
recommended as the agents of choice in a patient with chronic
tension-type headache.
4. Non pharmacological therapy
Complimentary therapies
Stress management
Alternative medicine
3. Prophylaxis
For the patient with more than two severe attacks of migraine monthly
• First line choices: Propranolol, Pizotifen, Amitriptiline
• Second line choice: Topiramate 25 mg – 50 mg at night.
See BNF for further advice about the doses
• Referral for BOTOX treatment for Chronic migraine if 15 or more
migraine days monthly and the above treatment failed.
See BNF for further advice about the doses
Cervicogenic headache
Cluster headache
CHARACTERISTICS:
CHARACTERISTICS:
Cluster headache is trigeminal autonomic cephalalgia,
characterised by attacks of severe unilateral usually sharp short
lasting pain in a trigeminal distribution associated with ipsilateral
cranial trigeminal autonomic features (tearing from eye, drooping
eye lid, redness of face blocked nostril). Typically restlessness
during the attack.
1. Acute treatment
•Subcutaneous injection of 6 mg Sumatriptan is recommended as the first choice treatment
•Nasal sumatriptan or Zolmitriptan in patients who cannot tolerate subcutaneous sumatriptan.
•Oxygen 10 – 15 l/min, nasal mask in sitting position (see BASH guidelines)
2. Prophylaxis
•Verapamil 240-960 mg is recommended for the prophylaxis
•Topiramate 50-100 mg bd
See BNF for further advice about the doses
Refer each patient with suspected Cluster Headache to the Headache Clinic
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Usually occipital radiating to the frontal regions
Dull or tight band like sometimes sharp shooting
Mild to moderate in intensity
Worse with neck movements
No nausea
Not aggravated by physical activity
1. Acute treatment
Aspirin, Paracetamol and NSAID are recommended
2. Prophylaxis
Amitriptyline 25-75 mg per day, are recommended as the agents of choice where prophylactic
treatment is being considered in a patient with chronic Cervicogenic headache.
3. Non pharmacological therapy
Physiotherapy, complimentary therapies, Alternative medicine.
See BNF for further advice about the doses
Refer patient with neuralgia or radicular irritation for assessment to the
Headache Clinic
Analgesia overuse headache
Secondary headache
Red flags which should
prompt referral for further
investigation:
 New onset or change in
headache Thunderclap:
rapid time to peak
headache intensity
(seconds to 5 mins)
 Focal neurological
symptoms
 Non-focal neurological
symptoms (eg. cognitive
disturbance)
 change in headache
frequency, characteristics
or associated symptoms
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Abnormal neurological examination
Headache that changes with posture
Headache on awakening
Headache precipitated by physical exertion or
Valsalva manoeuvre (eg coughing, laughing,
straining)
 Jaw claudication or visual disturbance
 Meningeal signs eg. neck stiffness, fever,
 New onset headache in a patient with a history of HIV
infection
 New onset headache in a patient with a history of cancer.
Patients who present with headache and red flag features of
potential secondary headache should be referred to specialist
for further assessment and investigation, CT brain scan, in
some cases MRI.
Thunderclap Headache
•A high-intensity headache of rapid onset reaching maximum intensity in less than a
minute in most; subarachnoid haemorrhage is the commonest, other conditions can also
present (intracerebral haemorrhage, cerebral venous sinus thrombosis, arterial dissection,
pituitary apoplexy).
•Patients should be referred immediately to hospital for same day specialist
assessment and investigation CT brain scan performed preferably within 12 hours
of onset.
•If normal CT, patient should have a lumbar puncture, oxyhaemoglobin and bilirubin
should be included in CSF analysis, ASAP after 12 hours.
•In delayed presentations, lumbar puncture can be performed up to two weeks from
onset of symptoms.
CHARACTERISTICS:
Headache which is present for 15 days or more per month and which has developed or
worsened while taking regular symptomatic analgesia medication.
Medication overuse headache must be excluded in all patients with chronic daily
headache
Opioid-containing medications use or overusing triptans are at most risk.
Treatment:
•Opioid-containing analgesics should be considered for gradual withdrawal.
•If frequent headache persists after symptomatic medications have been withdrawn,
prophylactic agents should be considered (Amitriptyline 25-75 mg per day.
•! Abrupt withdrawal from medication can initially results in worsening of headache.
•Psychiatric co morbidity and dependence behaviour should be considered and treated.
•Referral to a psychiatrist or a clinical psychologist should be considered.
Further info: http://guidance.nice.org.uk/CG150
http://www.bash.org.uk/
http://www.migrainetrust.org/health-professionals/guidelines
Penrith Headache Clinic
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