Adult Headache Pathway

- Do you have a headache all the time or does it come & go? (Tension Type
Headache or Medicines Overuse Headache usually have pain all the time) Patient presents with
- If intermittent what do you do when you have the pain? (patients with
migraine want to lie/sit still when pain is bad, those with cluster headaches
headache Posterior headaches often relate
can’t sit still when having an attack) to cervicogenic headaches
- What tablets are you taking now and have you taken before?
Unlikely to be sinuses, TMJ
Red Flags - Headache that is new or unexpected in an individual patient dysfunction or teeth unless other
• Thunderclap headache (intense headache of “explosive” onset suggest SAH) Take history & examine including signs /symptoms indicative of this
• Jaw claudication (suggests temporal arteritis - take ESR /CRP & start steroids BP, temporal arteries (if age >
immediately) Consider medication – esp
50years) & fundoscopy
• Headache with atypical aura (duration >1 hour, or including significant / combined hormonal
prolonged motor weakness) contraception (CHC). If patient
Secondary
• Headache associated with postural change (bending) or coughing (possible has migraines with aura then
Exclude red flags headache -
raised ICP) CHC is contraindicated
non serious
• New onset headache in patient with history of cancer, especially if < 20 years
cause
• Unilateral red eye – consider angle closure glaucoma Consider facial pain trigeminal
• Remember carbon monoxide poisoning (also causes lethargy + nausea) neuralgia as a cause of
• Rapid progression of sub-acute focal neurological deficit Primary headache ‘headache’
• Rapid progression of unexplained cognitive impairment / behavioural
disturbance The major types are listed below – it is important
• Rapid progression of personality changes confirmed by witness where there to realise however that patients may have more Most people who attend their
is no reasonable explanation than one type, so can develop tension type GP with recurrent / chronic
• New onset headache in a patient with a history of HIV / immunosuppression headaches on underlying migraine, or medication headaches have migraine.
• New onset headache in a patient older than 50 years overuse with tension type headaches
• Headache causing patients to wake from sleep NICE recommends keeping a headache diary A recurrent severe headache
• Progressive headache, worsening over weeks or longer associated with nausea and
photophobia is 98% predictive
Consider admission, urgent MRI scan or 2ww of migraine
referral as appropriate

Migraine without aura Migraine with aura Tension type headache Medication Overuse Cluster headache
(TTH) Headache (MOH)

M:F (1:5 ratio)

Diagnostic criteria - at least 5 attacks Occurs in 1/3 of migraine Usually episodic Medication history is Affects M:F (3:1 ratio)
fulfilling criteria 1-4 sufferers Deemed chronic if >15days per crucial especially use Usually aged 20+ years
1) Lasts 4-72 hours untreated Aura 5-60 minutes prior to month Bouts last 6-12 weeks
of over the counter
2) At least 2 of the following headache Stress is common trigger but not Usually occurs 1-2 x a year, often at
Unilateral location Usually visual – note blurring & always obvious
analgesia. Can occur same time of year.
Pulsating quality spots not diagnostic with other headache types Rarely chronic throughout year
Moderate/severe pain Can occur in combination with Prophylaxis medication Very severe – often at night & lasts 30-
3) Nausea / vomiting and/or photophobia Chronic migraine with or migraine and secondary doesn’t help & can worsen 60 minutes
4) No other cause identified without aura occurring headache triggers especially Medication overuse Strictly unilateral
Chronic migraine with or without aura everyday needs specialist cervicogenic /neck problems headache improves within Ipsilateral conjunctival injection,
occurring everyday needs specialist review 3 months of analgesic rhinorrhoea +/- Ptosis confirm
cessation.
review

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 Adult Headache
Migraine Pathway
with / without aura Tension Type headache (TTH) Cluster headache

Step 1- For acute attacks simple analgesic & triptan – Step 1 - Simple analgesic (avoid opioids) along with Most patients with new onset cluster headaches will
evidence suggest combination maybe best explanation & reassurance. Look at triggers and consider require referral to a neurologist for advice.
- consider adding anti-emetic medicine overuse headache (MOH)
- avoid opioids
Step 1- though short lived medication is nearly always
Triptans – may need to try more than one type. Step 2 - consider alternative NSAID such as naproxen needed (subcut sumatriptan is gold standard but consider
Care needed - however as frequent use can lead to triptan 500mg bd – maybe worthwhile taking regularly for 4-6 weeks intranasal triptan). Oxygen should only be prescribed if
overuse headaches (a form of MOH). Aim to use <2 if headaches are severe (with PPI cover if needed) recommended by a neurologist (link to guidance).
doses/week (see notes)
Usually prophylaxis is the best option
Use most cost-effective first
Step 3 - consider additional therapies eg acupuncture Note: β-blockers should not be used for cluster headaches
Also note migraines often return 48-72 hours post use of a
triptan
Step 2 - Prophylaxis
Step 4 - if headaches are severe, frequent & persist consider
Prophylaxis dose should be increased rapidly; most
amitriptyline starting at low dose of 10mg at night, slowly
Step 2 - consider rectal analgesic (diclofenac) but be aware sources suggest verapamil as first line
increasing to 75-150mg
of MHRA guidance Verapamil 80mg TDS starting dose then increase dose
(if possible avoid opiates) together with explanation & reassurance (see notes) Note: β-blockers not usually helpful & benzodiazepines as prednisolone withdrawn
should be avoided. SSRIs not helpful unless there is Prednisolone should be started at the same time as
underlying depression verapamil - 60-100mg daily for 5 days then decrease by
If headaches are frequent &/or acute medication is used very 10mg every 3 days, so that treatment is discontinued
frequently, prophylaxis should be considered. This should be Can also consider TENS and cognitive therapies after 2-3 weeks
titrated until control is gained and may take 6-8 weeks before
beneficial effects are seen. Usually needs to be continued for TENS and cognitive therapies
Reconsider and exclude red flags again (see part 1). Remember - lifestyle measures may
at least 6 months before considering a trial without Also consider mixed headaches – Migraine & TTH help
and / or Medicine Overuse Headache
Medicine Overuse Headache (MOH)
st
Prophylaxis - 1 line
β-blockers-propanolol 80-240mg in divided doses Consider whether MRI should be NO - MRI not - Only treatment is withdrawal
Or part of diagnostic process (where appropriate. Further - Symptoms may initially worsen on
Topiramate* - 25mg od to max 50mg bd (now recommended available) advice needed about withdrawal
by NICE) diagnosis or - Education & communication is critical.
*Please see additional notes for license comments. Note management
Yes and patient Can occur on top of other types of
topiramate is an enzyme inducer so care is needed with
Accepts MRI scan headaches
combined OCP/POP. Can cause foetal abnormalities -
contra-indicated in pregnancy & in women of
childbearing potential if not using effective methods of Abnormal MRI
MRI SCAN scan or patient not Menstrual migraines can be identified via
contraception. headache diary. May respond to
reassured despite
hormonal Rx-see www.bash.org.uk
normal MRI or
(NB pizotifen now not recommended)
Normal MRI scan and need further
patient reassured – advice Care needed with pregnancy - these
nd continue with Rx – guidelines do not apply to pregnancy or
2 line children – see NICE & BASH guidelines
consider trials of higher
Amitriptyline before bed - initially small dose-10mg nocte, at www.bash.org.uk
dosages for longer
increasing to up to 150mg (consider anticholinergic burden; periods
and risk of serotonin syndrome) REFER
Nortriptyline - only use if amitriptyline is effective but patient Don’t forget patients often have more
unable to tolerate side effects than one type of headache

If no response consider value of MRI

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 Adult Headache Guideline

Nottingham and Nottinghamshire Adult Chronic Headache Pathway With Open

Access to MRI Scanning

The following information is to support prescribers regarding the medicines aspects

of the pathway, please refer to the BNF or Summary of Product Characteristics for
further information on contraindications, precautions, adverse effects and
interactions.

Treatment of acute migraine

A stepped approach is often recommended commencing as early as possible with an

analgesic and anti-emetics/pro-kinetic if required, and escalating to a 5HT1 receptor
agonist (triptan) if this approach fails.

Aspirin or ibuprofen with or Need to establish therapeutic levels quickly

without paracetamol aspirin 600-900mg or ibuprofen 400-600mg
paracetamol 1g
Metoclopramide or Metoclopramide 10mg or
Domperidone or Domperidone 20 mg or
Prochlorperazine (Buccal) Prochlorperazine (buccal) 3-6mg (available OTC for
adults 18 and over)
Diclofenac suppositories Diclofenac 50mg or 100mg – see notes below

Notes:
1. Please be aware of recent MHRA guidance on the use of anti-emetics and
diclofenac. Links to the guidance is available through
www.nottinghamshireformulary.nhs.uk
2. Medicine should be given as soon as the onset of an attack is recognised.
3. The addition of a gastric motility agent will aid gastric emptying, as well as
relieving nausea.
4. Anti-migraine medicine containing Metoclopramide are not suitable for patients
under the age of 20 years.
5. Since peristalsis is often reduced in migraine attacks, dispersible preparations
may be helpful.
6. Suppositories are useful if vomiting or severe nausea present.

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 Adult Headache Guideline

Treatment of acute migraine in pregnancy:

First line Non-pharmacological measures –

avoidance of triggers, relaxation
techniques and cognitive behavioural
therapy
Second line Paracetamol 1g
Third line Ibuprofen 200-400mg (avoid in 3rd
trimester)
Sumatriptan 50-100mg

Notes:
1. Many medicines are contraindicated or have limited evidence of safety in
pregnancy.
2. Risks and benefits must be discussed with the patient.
3. If treatment with medication is necessary, consider contraindications and co-
morbidities.
4. There is less evidence of safety for nonsteroidal anti-inflammatories (NSAIDs)
and triptans than for paracetamol.
5. Sumatriptan is the preferred triptan in pregnancy.

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 Adult Headache Guideline

Triptans (5HT1-receptor agonists)

Please see Nottinghamshire Formulary at www.nottinghamshireformulary.nhs.uk for

further medicine information. Try using the most cost-effective preparation first line,
current Nottinghamshire formulary triptans are listed below.

Quicker onset of action, shorter half Slower onset of action. Longer half life.
life Lower incidence of side effects and may
be useful where recurrence is a problem
Sumatriptan Tablets 50, 100mg Naratriptan Tablet 2.5mg
Injection 6mg per 0.5ml
Nasal spray 10mg or
20mg per 0.1ml/dose
Zolmitriptan Tablets 2.5mg or Frovatriptan Tablet 2.5mg
Melts 2.5, 5mg
Nasal spray 5mg per
0.1ml/dose
Rizatriptan Tablets and
orodispersible 5mg,
10mg
Oral Lyophilisate 10mg

Notes:
1. NICE recommends that oral triptans should be used first line and other
preparations only considered if these are ineffective or not tolerated.
2. A second Triptan should not be taken if the first dose is ineffective.
3. Triptans are contraindicated in, uncontrolled hypertension, or risk factors for
coronary heart disease or cerebral vascular disease.
4. Different Triptans have different profiles of 5HT site action. If the first Triptan tried
fails, it is worth trying alternative ones. A pragmatic approach would be to choose
the cheapest one from each group as a first line.
5. Orodispersible formulations obviate the need for water but do not get absorbed in
mouth.
6. Nasal spray is useful when vomiting is a problem.

Prevention of migraine

Prophylaxis is used to reduce the number of attacks in circumstances when acute

therapy, used appropriately, gives inadequate symptom control. There are no specific
guidelines as to when prophylaxis should be commenced. Considerations include
frequency, impact, failure of acute therapy, avoidance of medication overuse
headache. Review the need for continuing migraine prophylaxis six months after the
start of prophylactic treatment. The potential for teratogenic effects should be noted
particularly with anti epileptic medications. In line with NICE recommendations these
updated guidelines no longer include a recommendation to use pizotifen.

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 Adult Headache Guideline

Notes:
1. Propranolol, metoprolol and timolol are licensed, but only propranolol is on
formulary for this indication.
2. Start at the lowest dose and build up gradually. Maintain the maximum tolerated
dose for a minimum of 6 weeks before assessing. Discuss with patient at 6
months whether a gradual reduction and elimination of prophylactic medication
might be considered.
3. Amitriptyline is useful with co-existent tension type headache, disturbed sleep or
depression. Consider anticholinergic burden and risk of serotonin syndrome.
4. Note that gabapentin is not recommended by NICE for prophylactic treatment of
migraine.

Topiramate

Topiramate is licensed for migraine prophylaxis in adults, and it is now recommended

for use in the NICE headache clinical guideline. Nottinghamshire Area Prescribing
Committee has assigned topiramate as Amber 3 in the traffic light guidelines.

The SPC (summary of product characteristics) will have full information on cautions,
contra-indications and side effects.

Place in therapy
This will be tailored to each patient, but as highlighted in the headache pathway, it
should be considered when:

 The frequency of migraines is such that regular prophylaxis is warranted

 Advise women of childbearing potential that topiramate is associated with a

risk of foetal malformations and can impair the effectiveness of hormonal
contraception. It is contraindicated in pregnancy and in women of childbearing
potential if an effective method of contraception is not used.

Review
Continuing therapy should be reviewed every 6 months.

Dose
Note can take 6-8 weeks before maximum effect gained.

Commence topiramate at 25mg nightly, and increase (see below) if required.

Titration Schedule
The dosage should then be increased in increments of 25 mg/day administered at 1-
week intervals. If the patient is unable to tolerate the titration regimen, longer
intervals between dose adjustments can be used.

Some patients may experience a benefit at a total daily dose of 50 mg/day. The
recommended total daily dose of topiramate as treatment for the prophylaxis of
migraine headache is 100 mg/day administered in two divided doses. No extra
benefit has been shown from the administration of doses higher than 100 mg/day.

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 Adult Headache Guideline

Topiramate Dosage Morning Evening

Week 1 25mg
Week 2 25mg 25mg
Week 3 25mg 50mg
Week 4 50mg 50mg

Contraindications
Known hypersensitivity
Breast feeding
Pregnancy

Cautions
Avoid abrupt withdrawal
Hepatic impairment
Renal impairment
Topiramate has been associated with acute myopia with secondary angle closure
glaucoma, typically occurring within 1 month of starting treatment. Choroidal
effusions have also been reported. If raised intraocular pressures occur – seek
ophthalmology advice and stop topiramate as rapidly as possible

Side Effects
Nausea, dyspepsia and diarrhoea
Dry mouth and taste disturbance
25% of people experience anorexia/loss of appetite
Drowsiness, insomnia, dizziness
50% of people experience initial paraesthesia (which usually settles)

Rarely - reduced sweating metabolic acidosis and alopecia

Very rarely - leucopenia, thrombocytopenia and serious skin reactions

Interactions
Oestrogens – metabolism accelerated – reduced contraceptive effect
Progestogens – metabolism accelerated – reduced contraceptive effect
Glibenclamide – possibly reduces plasma concentrations
Lithium – possibly affects plasma concentration

Topiramate should be prescribed generically and tablets should be prescribed in

preference to capsules due to price difference. In patients with swallowing
difficulties, the contents of a capsule can be sprinkled on a small amount of food
immediately prior to administration.

For further information on contraindications, precautions, adverse effects and

interactions refer to the BNF or Summary of Product Characteristics.

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 Adult Headache Guideline

Useful Resources – these guidelines have been developed using NICE and
BASH guidelines below

1. NICE Clinical Guideline CG150: Headaches in over 12’s: diagnosis and

management (September 2012, updated November 2015)
https://www.nice.org.uk/guidance/cg150

2. NICE CKS: Migraine. Scenario: Migraine in pregnant or breastfeeding women

(Last reviewed April 2019) https://cks.nice.org.uk/migraine#!scenario:2

3. The British Association for the Study of Headache (BASH)

https://www.bash.org.uk/guidelines/

4. The International Headache Society http://ihs-classification.org/en/

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Self Help Resources

Patient UK – https://patient.info/brain-nerves/headache-leaflet

Migraine Trust - http://www.migrainetrust.org/

Organization for the understanding of cluster headaches - http://www.ouchuk.org

NHS Choices http://www.nhs.uk/conditions/Headache/Pages/Introduction.aspx

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About this Guideline

Original Authors & contributors in alphabetical order

Nikos Evangelou – consultant neurologist NUH

Rob Lenthall – consultant neuro-radiologist NUH
Alastair McLachlan – GP and clinical lead for NORCOMM
Tony Marsh – GP clinical Lead for NNE
Hugh Porter –GP and clinical lead for UNICOM
Guy Sawle consultant neurologist NUH
Adrian Wills – consultant neurologist NUH

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Reviewed and updated 2016

Tanya Behrendt, Hugh Porter, Nikos Evangelou and Roger Knaggs in consultation
with Nottinghamshire APC and member organisations.

Reviewed and updated January 2020

Hugh Porter and Richard Sheldrake, in consultation with CCG pharmacists and
Nottinghamshire APC.

Review due January 2023

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