Chronic Headache and Migraine - Obsolete Aug 2021

Principles of Management

Chronic primary headache and migraine can usually be managed in primary care after appropriate safety netting (see red flag section below).

There are numerous guidelines and pathways available both locally and nationally which can make management confusing for GPs.

Diagnosis and Imaging Guidelines

A useful starting point for guidance on diagnosis is the Clinical Knowledge Summary chapter on Headache assessment (updated October 2019). The diagnosis section of the  BASH guidelines (click on top link - BASH National Headache Management System for Adults 2019 - pages 9 to 18) is also useful and easy to read.

The NICE Diagnosis Table (PDF) for tension-type headache, migraine and cluster headache (CG150) is a one page summary to help differentiate between different types of primary headache.

Management Guidelines

Migraine is the most common severe form of primary headache with a global prevalence of around 1 in 7 people. There are useful guidelines from SIGN (last updated February 2018) on the Pharmacological management of migraine.

The Chronic Headache Care Pathway was developed locally in September 2007. They have been updated since, most recently in 2016 so please ignore the dates on the documents. Please refer to the below links to access these guidelines which also have advice on management of primary headaches:

Chronic Headache care pathway - full

Chronic Headache care pathway - quick reference

Botox for chronic migraine

Botox treatment for migraine is only funded in accordance with NICE advice on prevention of headaches in adults with chronic migraine (2012)

Botox treatment is therefore only usually considered on advice of a neurologist who has confirmed that these criteria are met as below:

Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine):

There is no locally agreed pathway to access botox injections directly, therefore please only refer if above criteria are met and advise patients that botox injections will not necessarily be offered unless appropriate and agreed by the neurologist.

Specialist Advice

This presentation (powerpoint) was made by Dr Luke Bennetto, Consultant Neurologist at NBT, during the Neurology Education Session in June 2012.  It contains hints, tips and other information that may help primary care clinicians manage patients with headache.

Useful Links

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

Headache assessment

Migraine

Medication overuse headache

Cluster headache 

Tension-type headache

SIGN provides information on the diagnosis and management of headache in adults including: primary headache disorders, secondary headache and chronic headache. Their headache guidelines were last updated in 2008:

Diagnosis and management of headache in adults

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.

Red Flags

Clinical knowledge summaries has a list of red flags that may indicate a serious cause of headache that may require emergency or urgent referral.

Please also see the Brain and CNS suspect cancer guidelines for advice on referral criteria for brain tumours and how to refer.

Referral

If management of headache in primary care is not successful then referral to secondary care neurology clinic may be considered.

SIGN guidelines suggest that referral to secondary care for migraine should be considered if 3 or more therapies in primary care have failed. 

Referrals should be submitted via eReferral.

Home oxygen for Cluster Headaches

A pathway for treatment of cluster headaches is currently undergoing consultation and will be published here when available.

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.