• NICE urges GPs to consider whether painkillers could be causing their patients' headaches
• Different headaches require different treatments and so a correct diagnosis is vital

People who regularly take medicines, such as aspirin, paracetamol and triptans could be causing themselves more pain than relief. New guidance out today (Wednesday 19 September) from the National Institute for Health and Care Excellence (NICE) advises GPs and other healthcare professionals to consider the possibility of “medication overuse” in their patients who have been taking medicines for up to half of the days in a month, over three months.

More than 10 million people in the UK experience regular or frequent headaches, making them one of the most common health complaints. They account for around 1 in 25 of GP consultations.

While common over-the-counter treatments are effective for easing the pain of occasional headaches, it has been estimated that up to 1 in 50 people experience headaches caused by medication overuse and that women are five times more likely to get them than men. They occur when people take painkillers or triptan drugs too often for tension-type (“every day”) headaches or migraine attacks. Doing this can reduce their effectiveness and cause further pain.

Martin Underwood, a GP and professor of primary care research at Warwick Medical School who chaired the guideline's development said: “We have effective treatments for common headache types. However, taking these medicines for more than ten or fifteen days a month can cause medication overuse headache, which is a disabling and preventable disorder.

“Patients with frequent tension-type headaches or migraines can get themselves into a vicious cycle, where their headaches are getting increasingly worse, so they take more medication which makes their pain even worse as they take more medication.

“I hope this guideline will improve awareness of medication overuse headache both in primary care and among the general public because prevention is simple and treatment is difficult. Explaining to patients that they should abruptly stop their medication, knowing that their headache will get much worse for several weeks before it will improve, is not an easy consultation.”

This is the first time that GPs and other generalist clinicians will have practical guidance from NICE on the symptoms and features to look out for to diagnose medication overuse and primary headaches (i.e. those not caused by underlying health problems) and how they should be managed.

Peter May, who helped develop this guideline and has personal experience of cluster headaches said: “Having experienced cluster headaches for twelve years and initially being told that I was suffering from migraines, I believe there is a real need for diagnosis to be improved.

“The pain I experience in an attack lasts around forty-five minutes to an hour, and is excruciating, like being stabbed in my eye with a red hot poker. It took two years for me to receive a correct diagnosis, but I believe I am one of the fortunate ones as I know people who have gone twenty years. There are effective treatments available but they differ according to the type of headache and so having a correct diagnosis as soon as possible is crucial.”

Dr Gillian Leng, Deputy Chief Executive of NICE said: “Although headache is the most common neurological problem seen by GPs and neurologists, many people are not receiving correct or timely diagnoses. The key features of medication overuse and the symptoms that distinguish the types of primary headache can be overlooked and concerns from patients about possible underlying causes can lead to unnecessary hospital investigations. These can mean people experience delays in receiving adequate pain relief from what can be an extremely disabling condition.

“Our guideline outlines the assessments and treatments that people should expect to receive for primary headaches and medication overuse. We hope that this will help GPs and other healthcare professionals to correctly diagnose the type of headache disorder and better recognise patients whose headaches could be caused by their over-reliance on medications.”

Regarding medication overuse, NICE advises the NHS to be alert to the possibility in people whose headache developed or worsened while they were taking the following drugs for three months or more:

• Triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or
• Paracetamol, aspirin and an NSAID [non-steroidal anti-inflammatory drug, e.g. ibuprofen], either alone or any combination, on 15 days per month or more.

In addition, the NICE guideline advises healthcare professionals not to refer their patients for brain scans (neuroimaging) solely for reassurance. Many referrals will be unnecessary with improved diagnostic assessments.

Manjit Matharu, an honorary consultant neurologist at the National Hospital for Neurology and Neurosurgery and guideline developer said: “By clearly outlining the common features associated with primary headaches, the guideline will improve recognition and empower healthcare professionals to manage headaches more effectively, with better targeting of treatments. Also, it will enable healthcare professionals to undertake investigations confidently while avoiding the need for unnecessary brain scans.

“Clearly, neuroimaging is still an important diagnostic tool, but most peoples' headaches will not be caused by brain tumours or other serious health problems, and so these should not be offered to patients solely for reassurance.”

Ends

Notes to Editors

About the clinical guideline

1. This is NICE's 150^th clinical guideline. It will be available on the NICE website from 00.01 Wednesday 19 September. Embargoed copies are available on request from the NICE press office.

2. Page 12 of the guideline lists the key features of the primary headaches (tension, migraine and cluster) to support healthcare professionals in their diagnosis.

3. For further information about headaches, including statistics and definitions of the different types of headache, please visit NHS Choices.

4. In June, NICE published guidance recommending Botox (botulinum toxin type A) to prevent headaches associated with chronic migraine. For further information, please visit the Migraine (chronic) - botulinum toxin type A guidance page.

5. A headache on its own is very rarely due to cancer. NICE's clinical guideline on referrals for suspected cancer clearly sets out the symptoms that GPs should look out for if they suspect a patient has a brain tumour. These include vomiting, drowsiness, headache with pulse-synchronous tinnitus, and change in personality or memory. For further information, please visit the Referral for suspected cancer guidance page.

Key facts

• More than 10 million people in the UK experience regular or frequent headaches, making them one of the most common health complaints
• Headache accounts for 1 in 25 (4%) of primary care consultations and up to 30% of neurology out-patient appointments. Current practice suggests that 97% of people with headache are managed in primary care
• More than 100,000 people are absent from work or school because of migraines every working day - this totals around 25 million days a year
• Cluster headache is a type of primary headache, which typically causes intense pain around one eye. It presents in clusters for a month or two at around the same time of year. Around 1 in 1,000 people are believed to experience these at some point in their lives. Over-the-counter medications tend not to ease symptoms, but there are several treatments (including preventative options) recommended in the new NICE guideline

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.