NICE on the management of headaches: Don't get one thinking about it!

This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE.

My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through the NICE guideline on “Headaches in over 12s: diagnosis and management”, or NICE guideline CG150.

I will summarise the guidance from a Primary Care perspective only.

I am not giving medical advice; this video is intended for health care professionals; it is only my interpretation of the guidelines and you must use your clinical judgement.  

There is a YouTube version of this and other videos that you can access here: 

• The Practical GP YouTube Channel: 

https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk

The NICE guideline CG150 “Headaches in over 12s: diagnosis and management” can be found here:

·      https://www.nice.org.uk/guidance/cg150/chapter/Recommendations

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·      Image by Drazen Zigic on Freepik

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Transcript

Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the NICE guideline on headaches and I will summarise the guidance from a Primary Care perspective only.

So, let’s jump into it.

We will start by looking at the diagnostic clinical features that could help differentiate between tension‑type headache, migraine and cluster headache.

·      First, we have the Pain location which:

o  In Tension headache:  is usually Bilateral

o  In Migraine: can be Unilateral or bilateral

o  And in Cluster headache: is Unilateral (usually around the eye, above the eye and along the side of the head/face)

·      Then we look at the Pain quality which:

o  In Tension headache: is usually Pressing or tightening and non‑pulsating

o  In Migraine: is generally Pulsating (although it can be described as throbbing or banging in those aged 12 to 17 years)

o  And in Cluster headache: it is Variable (sharp, boring, burning, throbbing or tightening)

·      The Pain intensity is:

o  Mild or moderate in Tension headache:

o  Moderate or severe in Migraine:

o  And Severe or very severe in Cluster headache:

·      In terms of the Effect on activities we find that:

o  Tension headache: Is Not aggravated by routine activities

o  Migraine: is Aggravated by, or causes avoidance of, routine activities

o  And Cluster headache: causes Restlessness or agitation

·      Looking at Other possible symptoms we find that:

o  Tension headache: doesn’t usually have any

o  Migraine: usually produces Sensitivity to light and/or sound or nausea and/or vomiting. There can also be aura symptoms, which we will cover in more detail later.

o  and Cluster headache: will normally present On the same side as the headache:

• red and/or watery eye
• nasal congestion and/or runny nose
• swollen eyelid
• forehead and facial sweating
• constricted pupil and/or drooping eyelid

·      and finally, in terms of Duration of the headache:

o  Tension headaches can be from 30 minutes to continuous:

o  Migraine: can be 4 to 72 hours in adults but 1 to 72 h in those aged 12 to 17 

o  And Cluster headache:  usually lasts 15 to 180 minutes

Episodic tension-type headaches or episodic migraines occur on fewer than 15 days per month. Chronic tension-type headaches or chronic migraines occur on 15 or more days per month for more than 3 months. Chronic migraine and chronic tension‑type headache commonly overlap so, if there are features of migraine, we will diagnose chronic migraine.

On the other hand, Episodic cluster headaches occur from once every other day to 8 times a day with a pain-free period of more than 1 month. Chronic cluster headaches have the same frequency, that is from once every other day to 8 times a day but with a pain-free period of less than 1 month in a 12-month period.

And now let’s look at Migraine with aura in more detail.

And we will Suspect aura with or without headache if the symptoms:

·      are fully reversible and

·      develop gradually over at least 5 minutes and

·      last for 5 to 60 minutes. 

And typical aura symptoms include:

·      visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)

·      sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)

·      and speech disturbance. 

We can diagnose migraine with aura if typical aura symptoms are present, but we will Consider further investigations and referral if the symptoms are atypical such as:

·      motor weakness 

·      double vision 

·      visual symptoms affecting only one eye 

·      poor balance or

·      decreased level of consciousness. 

We will Suspect Menstrual‑related migraine if it’s predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles. 

And now we will touch on Medication overuse headache, which we will Consider if taking the following drugs for 3 months or more:

·      triptans, opioids, ergots or combination analgesics on 10 days/month or more or

·      paracetamol, aspirin or an NSAID on 15 days per month or more. 

In terms of Management of all headache disorders we will consider further investigations and referral if there worrying symptoms or signs such as:

·      worsening headache with fever

·      thunderclap headache or a sudden‑onset headache with maximum intensity within 5 minutes

·      new‑onset neurological deficit

·      new‑onset cognitive dysfunction

·      change in personality

·      impaired level of consciousness

·      recent head trauma (within the past 3 months)

·      headache triggered by cough, Valsalva, sneeze or exercise

·      orthostatic headache (headache that changes with posture)

·      symptoms suggestive of giant cell arteritis- Branches of the carotid artery and the ophthalmic artery are usually involved, giving rise to symptoms of headache, visual disturbances and jaw claudication.

·      symptoms and signs of acute narrow angle glaucoma, which may include headache with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster headache by the presence of a semi‑dilated pupil compared with the presence of a constricted pupil in cluster headache.

·      And a substantial change in the headache. 

We will also consider further investigations and/or referral if there is new‑onset headache with:

·      compromised immunity, 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

·      and vomiting without other obvious cause. 

If we want to consider a headache diary, it should be followed for a minimum of 8 weeks.

Now let’s have a look at the acute and prophylactic treatments of the various types of headaches. 

For the Acute treatment of Tension‑type headache we will Consider aspirin, paracetamol or an NSAID but we will not offer opioids and because of Reye's syndrome, aspirin should not be offered to under 16s

For the Prophylactic treatment of tension-type headache we will Consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For the Acute treatment of Migraine with or without aura, we will Offer combination of an oral triptan and an NSAID, or an oral triptan and paracetamol. If aged 12 to 17 years consider a nasal triptan in preference, for example nasal sumatriptan. And For people who prefer to take only one drug, we will consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol.

We will not offer ergots or opioids for the acute treatment of migraine but we will Consider additional anti‑emetic even in the absence of nausea and vomiting. 

If oral preparations (or nasal preparations if aged 12 to 17 years) are ineffective or not tolerated:

·      we will consider a non‑oral preparation of metoclopramide or prochlorperazine (for example buccal prochlorperazine) and

·      we will consider adding a non‑oral NSAID or triptan if they have not been tried.

And following a recent update, NICE says that the drug Rimegepant can be used, only if:

·      at least 2 triptans have been tried before but were ineffective or

·      if triptans cannot be used, and Paracetamol and NSAIDs are not effective.

For migraine prophylaxis, we will advise that riboflavin (400 mg once a day) may be effective for some people and that this is available as a food supplement. We will also offer topiramate or propranolol and we will consider amitriptyline but we will not offer gabapentin. We will then Review the need for continuing migraine prophylaxis after 6 months.

When prescribing migraine prophylaxis, we will consider:

·      consider the risk of foetal malformations with topiramate

·      discuss the risk of reduced effectiveness of hormonal contraceptives with topiramate

·      explain the importance of effective contraception with topiramate, for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method, bearing in mind that we will not routinely offer combined hormonal contraceptives if there is migraine with aura. 

·      And we will Use caution when prescribing propranolol if there is a history of depression as they could be at an increased risk of using propranolol for self-harm.

If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks

For Menstrual-related migraine we will Consider frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected. 

And for Treatment of migraine during pregnancy, we will Offer paracetamol but we may Consider triptan or an NSAID after discussing the risks during pregnancy and we will Seek specialist advice for migraine prophylaxis during pregnancy. 

For the Acute treatment of Cluster headache we will Discuss with a specialist the need for neuroimaging for people with a first bout of cluster headache and we will then Offer oxygen and/or a subcutaneous or nasal triptan. 

When using oxygen for the acute treatment of cluster headache:

·      We will use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and

·      We will arrange provision of home and ambulatory oxygen. 

When using a subcutaneous or nasal triptan, we will prescribe an adequate supply calculated according to their history and on the manufacturer's maximum daily dose. 

And we will not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for cluster headache. 

As Prophylactic treatment of cluster headache, we will Consider verapamil and, The BNF says that it should be initiated under specialist supervision, including advice on ECG monitoring and we will seek specialist advice if it does not respond or during pregnancy. 

For Medication overuse headache we will Explain that it is treated by withdrawing the overused medication and we will Advise to stop overused medications for at least 1 month and to stop abruptly rather than gradually. 

We will also explain that headache is likely to get worse before they get better and we will provide them with close follow‑up and support, considering prophylactic treatment for the underlying primary headache disorder.

We will Consider specialist referral and inpatient management for people who are using strong opioids, or have relevant comorbidities, or if previous attempts have been unsuccessful. 

We will then Review the diagnosis and management 4 to 8 weeks after stopping overused medication. 

We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guideline. You must always use your clinical judgement.

Thank you for listening and goodbye.