Headache (adults)

Overview

Headache is one of the commonest symptoms in medical practice. The Neurology Service at Southmead Hospital and the ICB are working to change headache services to be able to support patients in general practice more quickly and to focus hospital services on those patients who cannot be managed in the community.

For headaches in children aged under 16  please see the Headaches (children) page.

The following advice applies to adults but some medications advised are only licensed in patients aged 18 and over (3) . These guidelines should therefore be used with caution in 16/17 year olds so please consider requesting advice and guidance or referral in this age group.

Differential diagnosis of common headaches

*Trigeminal autonomic cephagias

Cluster headache is one of the trigeminal autonomic cephalgias, and by far the most common. For further advice on management of these types of headaches, please see the article below:

• Overview of trigeminal autonomic cephalalgias: Nosologic evolution, diagnosis, and management - Annals of Indian Academy of Neurology 2018.

This article suggests that they may respond to indometacin 25mg TDS, or 50mg TDS (with omeprazole where appropriate), or occasionally to other medications.

Whom to refer

The commonest clinical questions are:

1. Should I be concerned by this headache? The absence of clinical red flag headache markers (see below) is an extremely reliable indicator of no serious pathology. Severity of symptoms bears no relationship to seriousness of cause. If you are uncertain, put in an advice and guidance request, which will be answered within 48 hours. If the situation is more acute, please call the on-call neurology consultant on 0117 4141917, who can advise. All headache enquiries should initially come via A&G or by phone, rather than as outpatient referrals. They will be dealt with more quickly and advice can be given to submit an outpatient referral if required.

2. When should I refer this severe, but not serious headache? The majority of headache referred to hospital is migraine +/- medication overuse headache. A careful history will often elicit a story of intermittent migraine evolving into tension type headache with analgesic overuse, sometimes months or years earlier. The standard recommendation is to withdraw analgesia and initiate prophylaxis. It is important to appreciate that this is a two stage process: Withdrawal of analgesia will cause a rebound usually for up to two weeks, but occasionally longer and effective prophylaxis does not prevent this stage, but it does help reduce the subsequent frequency of migraines.

The diagnostic features of the commonest primary headaches/ head pains are summarised in the table above. The first thing to look at is the temporal pattern. We are happy to give advice by A&G or by phone where options in general practice appear to have been exhausted, or to discuss patients whose headache does not fit into these clinical patterns. 

3. Should this patient with refractory headache be considered for specialist treatment (greater occipital nerve block - GON; botulinum toxin or anti CGRP antibodies)?

a.They must have at least 15 headache days per month of which eight have features of migraine. See headache diary 

b.They must have tried at least three prophylactic migraine agents in good doses – Recommended doses of migraine prophylactic agents table below.

c. Medication overuse has been managed.

d. Referrals will only be accepted with a completed referral form – see below.

e. GON may be considered for non-migrainous, but strictly unilateral headaches which meet criteria 3a, 3b and 3c.

Red Flags

The following red flags should be considered when assessing patients with headache, and may warrant more immediate or urgent treatment or investigation:

• Sudden onset headache: zero to peak < 5mins
• Patient on anticoagulants
• Immunosuppressed patient
• Patient with malignant disease
• Headache on change of posture
• Persistent nausea and vomiting
• Fever
• Persistent neurological symptoms
• Neurological signs/papilloedema
• Age > 55 and features of giant cell arteritis (see GCA Management Guidelines table below)

Options for further action include:

• Medical admission or weekday IUC professional line
• Neurology Telephone advice or HOT clinic
• Brain and CNS 2WW
• Giant cell arteritis

Before referral

Migraine Management Flow Chart

Suggested medication

Recommended doses of migraine prophylactic agents

Standard treatment for common headaches

***See BNSSG Chronic Pain guidelines 2022 in forumulary for full details***

GCA Management Guidelines 

For advice on initial management and referral please see the Giant Cell Arteritis page on Remedy.

Please also see further advice on recognising and managing GCA below:

• GCA diagnosis and treatment guidelines 2020

Referral

Please consider the use of Neurology Advice & Guidance before referral

For patients with migraine.

Please include a list of medications trialled within primary care and only refer if criteria are met, or advice and guidance has been sought initially.

Ideally please complete the standard migraine referral form and refer to NBT Neurology via eRS.

Botox injections for migraine may be available to certain patients where criteria are met (see whom to refer section above), but specific requests for botox treatment of migraine from GPs should not be made as this may not be appropriate and may not be offered.

For patients with other forms of headache

Please review the diagnostic and management advice above and if necessary obtain advice and guidance before considering referral. Please ensure a summary of previous investigations and treatments trialled in primary care are included.

Resources

Clinical Knowledge Summaries on Headache:

• (1)Headache - assessment
• (2)Headache - tension-type
• (3)Migraine
• (4)Headache - medication overuse
• (5)Headache - cluster

(6) Migraine Prevention Pathway - see BNSSG Formulary Central Nervous System Guidelines- mainly for secondary care use

Guidelines

Local Resources from neurology team

Standard Headache Diary

Advice & Guidance for Managing Chronic Headaches - can be sent to patients

Relaxation Exercises for Headache

These documents are available on the ICB website if you want to send a web link to patients:

https://bnssg.icb.nhs.uk/library/standard-headache-diary/

https://bnssg.icb.nhs.uk/library/relaxation-exercises-for-the-treatment-of-recurrent-headaches/

https://bnssg.icb.nhs.uk/library/advice-and-guidance-for-managing-chronic-headaches/

NICE Guidelines

(1) Headaches in over 12s: Diagnosis and Management (CG150) - updated December 2021

Clinical Knowledge Summaries - also provides advice on various aspects of headache assessment and management:

• Headache assessment
• Migraine
• Medication overuse headache
• Cluster headache 
• Tension-type headache

Exeter Headache Clinic is run by a GPSI with a special interest in headache.  It is a primary care based service and receives referrals from the whole of Devon for headache >6 months.  The website provides effective guidelines and pathways:

• Exeter Headache Clinic (web page)
• Headache - Who Should be Investigated for Brain Tumour in Primary Care? (PDF)

British Association for the Study of Headache (BASH) is a national member of the International Headache Society.  It provides links to news, research and guidelines; provides training courses for any interested physician; and consults on national policy issues. Their headache guidelines were last updated in 2010:

• BASH guidelines

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.