Guidance

Key priorities for implementation

Key priorities for implementation

The following recommendations were identified as priorities for implementation in 2012. In 2015, the evidence was reviewed for the key priority recommendation on prophylactic treatment, but no change was made to the recommended action. No changes were made to the other key priority recommendations.

Tension‑type headache, migraine and cluster headache

  • Diagnose tension‑type headache, migraine or cluster headache according to the headache features in table 1. Chronic migraine and chronic tension‑type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.

    See recommendations 1.2.2, 1.2.3 and 1.2.4 for more information on diagnosis of migraine with aura. [2012]

Medication overuse headache

  • Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

    • triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or

    • paracetamol, aspirin or an NSAID, either alone or any combination, on 15 days per month or more. [2012]

Management

All headache disorders

  • Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance. [2012]

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 explanation of the diagnosis and reassurance that other pathology has been excluded and

    • the options for management and

    • recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers. [2012]

Migraine with or without aura

Acute treatment

  • Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12 to 17 years consider a nasal triptan in preference to an oral triptan. [2012]

    In November 2015, this was an off-label use of triptans (except nasal sumatriptan) for under 18s. See NICE's information on prescribing medicines.

  • For people in whom oral preparations (or nasal preparations in young people aged 12 to 17 years) for the acute treatment of migraine are ineffective or not tolerated:

    • consider a non‑oral preparation of metoclopramide or prochlorperazine and

    • if non-oral metoclopramide or prochlorperazine is used, consider adding a non‑oral NSAID or triptan if these have not been tried. [2012]

      Note the special warnings and precautions for use in the summaries of product characteristics for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).

      In November 2015, only a buccal preparation of prochlorperazine was licensed for this indication (prochlorperazine was licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people. See NICE's information on prescribing medicines.

Prophylactic treatment

Topiramate: In June 2024, the Medicines and Healthcare products Regulatory Agency (MHRA) published a Drug Safety Update on topiramate. Topiramate should not be used for migraine prophylaxis in pregnancy. Topiramate should not be used in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled. See the MHRA's advice for health professionals to provide to patients currently taking topiramate. NICE is assessing the impact of this alert on recommendations in this guideline. 

  • For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:

Cluster headache

Acute treatment

  • Offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache. [2012]

    In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.

  • 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. [2012]

  • 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. [2012]

    In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.