Excerpt

Many non-specialist healthcare professionals can find the diagnosis of headache difficult, and both people with headache and their healthcare professionals can be concerned about possible serious underlying causes. This leads to variability in care and may mean that people with headaches are not always offered the most appropriate treatments. People with headache alone are unlikely to have a serious underlying disease. Comparisons between people with headache referred to secondary care and those treated in primary care show that they do not differ in terms of headache impact or disability.

Many people with headache do not have an accurate diagnosis of headache type. GPs lack confidence in their ability to diagnose common headache disorders. They can feel under pressure to refer people for specialist opinion and investigation. Most common headache types can be diagnosed on clinical history and can be managed in primary care. If specialist advice is needed on headache diagnosis and management this can be provided by a neurologist with an interest in headache or a GP with a special interest (GPwSI) in headaches, or for young people under 18 years of age; a general hospital or community based paediatrician or paediatric neurologist. Within this guideline the term specialist is used to mean either a neurologist, GPwSI, paediatric neurologist or paediatrician with a special interest in headache.

This guideline does not cover secondary headaches that require more specialist management, for example headaches that are due to an underlying infection (e.g. meningitis) and cervicogenic headache. Facial pain and occipital neuralgia are also beyond the remit of this guideline.

Contents

• Guideline development group members
• Acknowledgments
• 1. Introduction
  • Current practice
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline?
  • 2.2. Remit
  • 2.3. What this guideline covers
  • 2.4. What this guideline does not cover
  • 2.5. Relationships between the guideline and other NICE guidance
  • Methods
  • 2.6. Developing the review questions and outcomes
  • 2.7. Searching for evidence
  • 2.8. Evidence of clinical effectiveness
  • 2.9. Evidence of cost-effectiveness
  • 2.10. Developing recommendations
• 3. Guideline summary
  • 3.1. Algorithms
  • 3.2. Key priorities for implementation
  • 3.3. Full list of recommendations
  • 3.4. Key research recommendations
• Assessment and diagnosis
  • 4. Indications for consideration of additional investigation
    • 4.1. Introduction
    • 4.2. HIV positive with new onset headache
    • 4.3. History of malignancy with new onset headache
    • 4.4. Early morning headache or new onset frequent headache lasting for more than one month
    • 4.5. Recommendations and link to evidence
  • 5. Identifying people with primary headache
    • 5.1. Introduction
    • 5.2. Recommendations and link to evidence
  • 6. Headache diaries for the diagnosis and management of primary headaches and medication overuse headache
    • 6.1. Introduction
    • 6.2. Headache diaries as an aid to diagnosis
    • 6.3. Headache diaries as an aid to management
  • 7. Diagnosis of primary headaches and medication overuse headache
    • 7.1. Introduction
  • 8. The role of imaging in diagnosis and management of primary headaches
    • 8.1. Introduction
    • 8.2. Imaging for diagnosis in people with suspected primary headaches
    • 8.3. Imaging as a management strategy for people with suspected primary headaches
• Management
  • 9. Information and support for people with headache disorders
    • 9.1. Introduction
    • 9.2. Literature review
    • 9.3. Recommendations and link to evidence
  • 10. Acute pharmacological treatment of tension type headache
    • 10.1. Introduction
    • 10.2. Matrix of treatment comparisons
    • 10.3. Recommendations and link to evidence
  • 11. Acute pharmacological treatment of migraine with or without aura
    • 11.1. Introduction
    • 11.2. Oral, nasal and self administered subcutaneous treatments
    • 11.3. Intravenous, intramuscular and subcutaneous administered treatments
    • 11.4. Network Meta-analysis
    • 11.5. Economic evidence
    • 11.6. Recommendations and link to evidence
  • 12. Acute pharmacological treatment of cluster headache
    • 12.1. Introduction
    • 12.2. Matrix of treatment comparisons
    • 12.3. Recommendations and link to evidence
  • 13. Prophylactic pharmacological treatment of tension type headache
    • 13.1. Introduction
    • 13.2. Matrix of treatment comparisons
    • 13.3. Recommendations and link to evidence
  • 14. Prophylactic pharmacological treatment of migraine with or without aura
    • 14.1. Introduction
    • 14.2. Matrix of treatment comparisons
    • 14.3. Network meta-analysis
    • 14.4. Economic evidence
    • 14.5. Recommendations and link to evidence
  • 15. Prophylactic pharmacological treatment of menstrual migraine
    • 15.1. Introduction
    • 15.2. Matrix of treatment comparisons
    • 15.3. Recommendations and link to evidence
  • 16. Prophylactic pharmacological treatment of cluster headache
    • 16.1. Introduction
    • 16.2. Matrix of treatment comparisons
    • 16.3. Recommendations and link to evidence
  • 17. Prophylactic non-pharmacological management of primary headaches with acupuncture
    • 17.1. Introduction
    • 17.2. Tension type headache
    • 17.3. Migraine with or without aura
    • 17.4. Recommendations and link to evidence
  • 18. Prophylactic non-pharmacological management of primary headaches with manual therapies
    • 18.1. Introduction
    • 18.2. Tension type headache
    • 18.3. Migraine with or without aura
    • 18.4. Recommendations and link to evidence
  • 19. Prophylactic non-pharmacological management of primary headaches with psychological therapies
    • 19.1. Introduction
    • 19.2. Tension type headache
    • 19.3. Migraine with and without aura
    • 19.4. Recommendations and link to evidence
  • 20. Prophylactic non-pharmacological management of primary headache with dietary supplements and herbal remedies
    • 20.1. Introduction
    • 20.2. Dietary supplements
    • 20.3. Herbal remedies
    • 20.4. Recommendations and link to evidence
  • 21. Prophylactic non-pharmacological management of primary headaches with exercise
    • 21.1. Introduction
    • 21.2. Recommendations and link to evidence
  • 22. Prophylactic non-pharmacological management of primary headaches with education and self management
    • 22.1. Introduction
    • 22.2. Recommendations and link to evidence
  • 23. Management of medication overuse headache
    • 23.1. Introduction
    • 23.2. Recommendations and link to evidence
• Management during pregnancy and contraceptive use
  • 24. Management of primary headaches during pregnancy
    • 24.1. Introduction
    • 24.2. Recommendations and link to evidence
  • 25. Combined hormonal contraception use in girls and women with migraine with or without aura
    • 25.1. Introduction
    • 25.2. Recommendations and link to evidence
• 26. Abbreviations
• 27. Glossary
• 28. Reference list
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Review protocols
  • Appendix D. Literature search strategies
  • Appendix E. Evidence tables – Clinical evidence
  • Appendix F. Evidence tables – Economic evidence
  • Appendix G. Forest plots – Clinical evidence
  • Appendix H. 2×2 tables for diagnostic reviews
  • Appendix I. Network meta-analysis of pharmacological interventions for the acute treatment of migraine
  • Appendix J. Cost-effectiveness analysis: Acute pharmacological treatment of migraine
  • Appendix K. Network meta-analysis of pharmacological interventions for the prophylactic treatment of migraine
  • Appendix L. Cost-effectiveness analysis – Prophylactic treatment of migraine
  • Appendix M. Research recommendations
  • Appendix N. Excluded studies
  • Appendix O. Adapted PRISMA flow diagrams
  • Appendix P. References