Headache Algorithm

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⚡ Snapshot. The whole pathway on one page: act now, triage, classify, treat today and safety-net. The Steps tab holds the detail.

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Safety

Exclude life-threatening causes first

Done

Ask screening questions before anything else. A single missed subarachnoid haemorrhage is career-ending. Screen every new headache patient.

Thunderclap onset "Worst headache of my life", peaking within 1–5 minutes (NICE NG228) → 999 Immediate transfer to emergency care — SAH until proven otherwise; also RCVS, cervical artery dissection, CVST, pituitary apoplexy, spontaneous intracranial hypotension, primary thunderclap headache, migraine. No outpatient CT or LP; in hospital, urgent senior review and non-contrast CT

Focal neurology New limb weakness, facial droop, dysphasia, diplopia, ataxia → 999 Stroke / cerebral venous sinus thrombosis / posterior fossa lesion

Meningism Neck stiffness, photophobia, non-blanching rash, Kernig's sign, fever → 999 Bacterial meningitis / meningoencephalitis

Papilloedema / raised ICP Postural worsening, worse lying flat/morning, vomiting, visual obscurations → Same day Brain tumour / IIH / CVST — same-day emergency/specialist assessment; urgent neuroimaging per hospital pathway (usually MRI with venography; CT if MRI unavailable or an acute emergency must be excluded). No LP before imaging

Carbon monoxide Others at home (or pets) unwell, better away from home, a gas or solid-fuel appliance, no CO alarm → Same day Get everyone out, stop the appliance, ventilate; same-day assessment

Head trauma Anticoagulated, skull fracture signs (Battle's sign, panda eyes, CSF rhinorrhoea), GCS <15 → 999 Subdural / extradural haematoma; NICE NG232 Head injury (2023)

Temporal arteritis Age ≥50 with new headache plus jaw/tongue claudication, scalp tenderness, visual symptoms or constitutional features → Same day Giant cell arteritis; if suspicion significant start prednisolone (usually 40–60 mg) immediately — do not wait for bloods, biopsy or imaging; visual loss → IV methylprednisolone 0.5–1 g for up to 3 days, or prednisolone 60 mg orally if IV is not immediately available, plus same-day ophthalmology (BSR). Normal ESR does not exclude GCA

New headache in pregnancy / postpartum New or severe headache after 20 weeks or postpartum, especially with hypertension, visual symptoms, epigastric pain, vomiting, hyperreflexia, seizures or abnormal bloods → Same-day obstetric Pre-eclampsia / HELLP / cerebral venous thrombosis; 999 if severe hypertension, seizure, altered consciousness, neurological deficit or maternal instability

Immunocompromised / HIV Subacute onset, weight loss, night sweats → Same day Cryptococcal meningitis / cerebral toxoplasmosis / CNS lymphoma; same-day acute assessment — imaging/LP via hospital pathway

New headache in cancer patient Known malignancy, progressive headache, personality change → Urgent / same-day if rapidly progressive — brain metastases; urgent MRI

Acute angle-closure glaucoma Periorbital pain, eye redness, haloes, nausea, vomiting → Emergency eye unit now Phone the eye unit and send directly (same day, immediately) — irreversible visual loss within hours without treatment

Subarachnoid haemorrhage carries high mortality and is often initially misdiagnosed — most often as migraine or tension headache. A sentinel headache ("warning leak") may precede a catastrophic bleed. A thunderclap headache mandates 999 regardless of subsequent resolution.

GCA can cause permanent visual loss if untreated. Treatment must not wait for biopsy results. ESR and CRP support the diagnosis but neither is diagnostic, and ESR may be normal. Take bloods only if this does not delay steroids.

NICE NG12 (updated April 2026) recommends considering an urgent direct-access MRI brain (CT if MRI is contraindicated), done within 2 weeks, for adults with progressive, sub-acute loss of central neurological function. A new seizure or headache with known cancer is a clinical red flag for same-day or urgent assessment, not an NG12 criterion. Raised ICP features indicate same-day assessment rather than the NG12 urgent MRI route.

Diagnose

Characterise the headache — SOCRATES + triggers

Done

Systematic history is your most powerful diagnostic tool. Most primary headaches are diagnosed on history alone.

Site

Unilateral (migraine, cluster) vs bilateral (tension-type, medication overuse). Occiput (cervicogenic, SAH). Periorbital (cluster, GCA, glaucoma).

Onset

Thunderclap (peak within 1–5 min, NG228) → SAH. Gradual over weeks → raised ICP, medication overuse, depression. Recurrent episodic → migraine, tension-type.

Character

Throbbing / pulsating → migraine. Band-like pressure → tension-type. Severe stabbing / ice-pick → trigeminal autonomic cephalalgias or primary stabbing headache.

Radiation

Neck (meningism, cervicogenic). Jaw / temple (GCA). Behind eye (cluster, glaucoma).

Associated symptoms

Nausea/vomiting, photophobia, phonophobia → migraine. Lacrimation, rhinorrhoea, eyelid ptosis / miosis → cluster. Aura (visual, sensory, speech) → migraine with aura.

Time course

Duration: 4–72 h = migraine; 15 min–3 h = cluster; 30 min–7 days = tension-type. Frequency: >15 days/month → chronic daily headache / medication overuse.

Exacerbating

Movement, coughing, sneezing (raised ICP). Menstruation, OCP, alcohol, sleep disruption (migraine). Stress (tension-type). Alcohol triggers cluster within 1 hour.

Relieving

Triptan response supports migraine diagnosis (but not diagnostic alone). Darkness/sleep for migraine. Cluster: agitation — patients pace, do not lie still (distinguishes from migraine).

Severity (0–10)

Rate at peak. ≥8/10 with rapid onset demands urgent exclusion of SAH even if previous similar attacks documented.

Diary request

Ask patient to complete a headache diary for at least 8 weeks (NICE CG150): date, duration, severity, triggers, medications used. Essential for diagnosis and overuse assessment. Migraine Trust diary app available free.

Headache diaries improve diagnostic accuracy significantly and reveal medication overuse patterns invisible in consultation. Patients frequently underestimate both frequency and analgesic use. NICE CG150 advises considering a headache diary to aid diagnosis, kept for at least 8 weeks.

Cluster headache is extremely painful and is frequently misdiagnosed as migraine or sinusitis. Restlessness and agitation during attacks are characteristic.

Diagnose

Classify the headache type using ICHD-3 criteria

Done

Apply ICHD-3 (International Classification of Headache Disorders) criteria. Classification drives treatment — analgesic choice differs entirely between migraine and tension-type.

Migraine without aura

≥5 attacks lasting 4–72 h + ≥2 of: unilateral, pulsating, moderate/severe, worse with activity + ≥1 of: nausea/vomiting OR photophobia AND phonophobia. ICHD-3: 1.1

Migraine with aura

≥2 attacks; fully reversible aura symptoms (visual, sensory, speech/language) spreading gradually or occurring in succession, each usually lasting 5–60 min, followed by headache within 60 min. Motor, brainstem or retinal aura → specialist. ICHD-3: 1.2

Chronic migraine

≥15 headache days/month for >3 months, with migraine features on ≥8 days/month. ICHD-3: 1.3

Tension-type headache

Episodes 30 min–7 days; ≥2 of bilateral, pressing/tightening, mild–moderate, not worsened by routine activity; no nausea or vomiting. Episodic: <15 days/month. Chronic: ≥15 days/month for >3 months. ICHD-3: 2

Cluster headache

Severe unilateral orbital/supraorbital pain lasting 15–180 min, ≥1 ipsilateral autonomic feature (lacrimation, conjunctival injection, ptosis, rhinorrhoea, miosis), agitation, ≥1 attack/48 h in cluster period. ICHD-3: 3.1

Medication overuse headache

Headache ≥15 days/month + triptans, opioids, ergots or combination analgesics on ≥10 days/month, or paracetamol, aspirin or NSAIDs on ≥15 days/month, for ≥3 months. MOST COMMON cause of chronic daily headache in UK primary care. Screen all frequent headache patients. Very common

Cervicogenic headache

Unilateral, from neck, reduced neck range of movement, precipitated by neck movement/posture, responds to cervical blockade or physiotherapy. Often coexists with migraine.

New daily persistent headache

Daily from exact onset date, lasting >3 months. Requires assessment for secondary causes. Urgent imaging/referral if red flags, abnormal examination, systemic symptoms, immunosuppression, cancer or atypical features; papilloedema → same-day assessment. Can be post-viral (including post-COVID). Refer to neurology/headache services if the diagnosis remains uncertain or symptoms persist.

Idiopathic intracranial hypertension

Obese woman of childbearing age + daily headache + visual obscurations + pulsatile tinnitus + bilateral papilloedema. CSF pressure >25 cmH₂O on LP. Same day new papilloedema needs same-day specialist assessment (eye service/neurology/acute) for imaging (vision at risk — not a suspected cancer pathway)

Medication overuse headache (MOH) is caused by use of triptans, opioids, ergots or combination analgesics on ≥10 days/month, or paracetamol, aspirin or NSAIDs on ≥15 days/month, for ≥3 months (NICE CG150). It transforms episodic migraine into chronic daily headache. The treatment is withdrawal — not escalating preventives while overuse continues. Preventives are ineffective while overuse persists.

IIH is increasing in prevalence with rising obesity rates. It causes permanent visual field loss if missed. All obese young women with daily headache deserve fundoscopy to check for papilloedema.

Diagnose

Targeted examination

Done

Examination rarely changes diagnosis in primary headaches, but is essential to exclude secondary causes and reassure patients. Document findings clearly.

Blood pressure

Measure BP. Hypertensive crisis (systolic >180) can cause headache. Malignant hypertension with papilloedema → same-day referral. Compare both arms only if aortic dissection, unequal pulses, vascular disease or severe unexplained hypertension is a concern (significant inter-arm difference → consider dissection).

Fundoscopy

Papilloedema = raised ICP until proven otherwise → same-day referral. Perform where trained and the view is reliable; absence of detected papilloedema in primary care does not exclude raised ICP. Record: disc margins sharp/blurred, venous pulsation present/absent.

Temporal arteries

Palpate for tenderness, thickening, nodularity, absent pulsation in patients ≥50 with new headache and compatible symptoms. GCA diagnosis requires assessment even if ESR is normal.

Full neurological exam

Cranial nerves, upper and lower limb power/reflexes/coordination, gait. Any focal deficit → same-day referral. Document clearly. Normal exam is reassuring but never excludes pathology.

Neck examination

Range of movement, meningism (Kernig's, Brudzinski's, nuchal rigidity). Neck stiffness + fever → 999.

Eyes

Visual acuity (Snellen), visual fields by confrontation, pupil reactions. Fixed mid-dilated pupil + severe pain → acute angle-closure glaucoma → phone the emergency eye unit and send directly now. Horner's syndrome (miosis, ptosis, anhidrosis) with cluster headache.

BMI

Obesity (BMI >30) in young woman → screen for IIH. BMI is a modifiable risk factor for migraine frequency.

Pericranial muscles

If relevant (not needed in every consultation), palpate temporalis, masseter, sternocleidomastoid. Tenderness present in tension-type headache. TMJ dysfunction may contribute.

Fundoscopy is an important examination in new headache presentations when it can be performed reliably. Many GPs are deskilled — arrange ophthalmology referral if unsure of findings. Absence of venous pulsation is an early sign of raised ICP.

Normal neurological examination does not exclude a brain tumour — many present without focal signs. The combination of progressive headache + personality change + cognitive decline requires imaging even with a normal examination.

Diagnose

Investigations — when to test and what to request

Done

Most primary headaches require NO investigations. Over-investigation causes anxiety without benefit. Investigate only when the history or examination suggests a secondary cause.

ESR + CRP Blood

Request if ≥50 years with new headache, jaw claudication, scalp tenderness. ESR and CRP support the diagnosis but neither is diagnostic, and ESR may be normal. Take FBC, ESR, CRP, U&Es, LFTs and glucose if this does not delay treatment. Do not delay prednisolone for results if GCA is suspected clinically.

FBC, U&E, TFTs Blood

Guided by clinical context — not routine in typical migraine or tension-type headache with normal examination. FBC: anaemia, systemic disease or bleeding. U&E: systemic illness, renal disease, electrolyte disorder or relevant medication. TFTs: clinical features of thyroid disease. Pregnancy test where appropriate.

Glucose Blood

Hypoglycaemia causes headache. Check if diabetes, hypoglycaemic symptoms or acute illness.

CT head Imaging

DO NOT request routinely for migraine / tension-type headache — does not reduce patient anxiety (evidence shows this). Via the hospital/emergency pathway for: suspected SAH (urgent non-contrast CT; accuracy depends on timing, scanner and reporting), focal neurology, first seizure, new headache in immunocompromised. Suspected raised ICP: usually MRI with venography; CT if MRI unavailable or an acute emergency must be excluded. Avoid routine CT

MRI brain Imaging

Superior to CT for posterior fossa, pituitary, white matter lesions. Request (via neurology referral if appropriate) for: new daily persistent headache with red flags, abnormal examination or atypical features, suspected IIH (with MRV for CVST), aura without headache, atypical migraine features.

LP (in hospital) Procedure

NICE NG228: if CT within 6 hours is negative and reported by an appropriately experienced radiologist, do not routinely perform LP — seek senior advice and consider alternative diagnoses. If CT after 6 hours is negative, consider LP at least 12 hours after onset for xanthochromia. Never before imaging has excluded a mass lesion or obstructive hydrocephalus. Arrange same-day hospital attendance; do not perform in primary care. Opening pressure diagnostic for IIH (>25 cmH₂O).

DO NOT investigate

Typical migraine with normal examination. Typical tension-type headache. Reassurance is more effective than imaging in primary headaches (meta-analysis data).

CT accuracy for SAH is highest within 6 hours and falls with time; it also depends on scanner quality and radiologist expertise. A negative CT more than 6 hours after onset does not exclude SAH — consider LP (NICE NG228). The Ottawa SAH rule can guide decision-making.

Routine neuroimaging for migraine is specifically not recommended by NICE CG150. Studies show it increases false-positive incidental findings, patient anxiety, and NHS costs without improving outcomes. Reserve CT/MRI for atypical features only.

Refer

Referral criteria — who, when, how urgently

Done

Know your local neurology and ophthalmology pathways. Many areas now have rapid access headache clinics — check your local pathways.

999 Emergency

Thunderclap headache, focal neurology + headache, meningism, papilloedema + acute-onset, GCS <15, non-blanching rash + headache + fever, acute visual loss + headache (including GCA with visual symptoms), painful diplopia or new III nerve palsy (posterior communicating artery aneurysm until proven otherwise), suspected acute stroke/posterior circulation stroke, severe headache in pregnancy/postpartum with severe hypertension, seizure, altered consciousness or neurological deficit.

Same day Urgent

Suspected GCA (start prednisolone immediately, refer same-day to rheumatology/ophthalmology). New headache in immunocompromised. Suspected cerebral venous thrombosis (headache + focal signs + pregnancy/OCP). Headache with new papilloedema on any same-day fundoscopy (including suspected IIH). Pregnancy/postpartum headache with hypertension or systemic features (same-day obstetric assessment). New headache with cancer plus progression or neurological symptoms. Headache with new visual symptoms.

NICE NG12 Urgent direct-access MRI

NICE NG12 (updated April 2026): progressive, sub-acute loss of central neurological function (for example progressive personality or cognitive change) → consider urgent direct-access MRI brain within 2 weeks (CT if MRI contraindicated). New headache with known cancer, a new seizure, or unexplained visual deterioration are not NG12 criteria — assess the same day or refer urgently on clinical grounds.

Routine Neurology

Refractory migraine not controlled with ≥2 preventives. Suspected cluster headache — all for specialist confirmation, especially first presentation or atypical age/features (initiate verapamil). New daily persistent headache. Hemiplegic migraine. Migraine with brainstem aura. Atypical aura. Medication overuse headache not responding to withdrawal strategy.

Ophthalmology (same day)

GCA with visual symptoms (visual loss: IV methylprednisolone 0.5–1 g for up to 3 days, or prednisolone 60 mg orally if IV is not immediately available). Acute angle-closure glaucoma — phone the emergency eye unit and send directly now. Papilloedema on fundoscopy. Painful diplopia or III nerve palsy is not an eye referral — 999 (posterior communicating artery aneurysm until proven otherwise).

Rheumatology (urgent)

GCA: refer same day alongside prednisolone commencement. Temporal artery biopsy within 2 weeks of starting steroids. Check local pathway — some areas manage GCA in primary care under specialist guidance.

Primary care management

Episodic migraine responding to acute treatment. Episodic tension-type headache. Medication overuse headache without opioid/benzodiazepine complexity (withdrawal + support). Stable cervicogenic headache (physiotherapy) once secondary causes are excluded. Headache associated with stress/anxiety/depression (psychological interventions).

Cluster headache is best initiated under neurological supervision. Verapamil (first-line prophylaxis, up to 480 mg/day) requires ECG monitoring before and after dose escalation due to risk of heart block. Subcutaneous or nasal triptan and high-flow oxygen (at least 12 L/min via non-rebreather mask with reservoir bag, with home oxygen arrangements) are first-line acute treatments; oral triptans are not suitable as the principal acute treatment.

III nerve palsy + headache mandates 999 transfer for emergency imaging and neurosurgical assessment — a posterior communicating artery aneurysm compresses the oculomotor nerve from outside, producing a painful, pupil-involving third nerve palsy. This is a neurosurgical emergency with catastrophic rupture risk.

NICE NG12 (updated April 2026) supports urgent direct-access MRI brain for progressive, sub-acute loss of central neurological function; headache alone is not an NG12 criterion. The RCP recommends urgent-access headache clinics (seen within 2 weeks) rather than A&E for urgent but non-emergency cases.

Treat

Drug ladder — acute and preventive treatment

Done

Treat the right condition. Ensure medication overuse is excluded before starting preventives. Counsel patients that preventives take 8–12 weeks to achieve full effect.

Migraine — Acute Treatment

Acute migraine (NICE CG150)

Oral triptan + NSAID or paracetamol 1st line

Offer an oral triptan plus an NSAID or paracetamol, taking account of comorbidity and patient preference. If one drug is preferred: triptan, NSAID, aspirin 900 mg or paracetamol. Add an antiemetic if needed, even without nausea (metoclopramide 10 mg — max 5 days, dystonia risk, esp. young women — or prochlorperazine). Avoid opioids and ergots.

Triptan choice / non-oral routes

Triptan options 1st line

Sumatriptan 50–100 mg PO (or 6 mg SC for fastest onset, or 20 mg nasal spray). Zolmitriptan 2.5 mg PO / nasal if sumatriptan fails. Avoid in cardiovascular disease, uncontrolled hypertension, haemiplegic migraine. If oral treatment is ineffective or not tolerated: non-oral metoclopramide or prochlorperazine, plus a non-oral NSAID or triptan.

Triptan + NSAID combination

Sumatriptan + Naproxen Combination

Prescribe separately (e.g. sumatriptan 50–100 mg + naproxen 500 mg), taking account of comorbidity. Combination therapy is the NICE-preferred first-line approach.

Menstrual migraine (perimenstrual only)

Frovatriptan / Zolmitriptan Mini-prophylaxis

Frovatriptan 2.5 mg BD or zolmitriptan 2.5 mg BD–TDS on the days migraine is expected (NICE CG150); BASH also lists naratriptan 1 mg BD, typically starting 2 days before expected onset. Longer half-life than sumatriptan.

≥2 triptans failed / triptans contraindicated

Rimegepant 75 mg ODT NICE TA919

CGRP-receptor antagonist (gepant). NICE TA919: after ≥2 triptans have not worked adequately, or if triptans are contraindicated/not tolerated and NSAIDs and paracetamol are ineffective. No vasoconstriction, but check indication, interactions, renal/hepatic impairment, current SPC and local prescribing arrangements. Also recommended by NICE TA906 (2023) for PREVENTION of episodic migraine (4 to under 15 attacks a month) at 75 mg alternate days after 3 or more preventives have failed, not been tolerated or are unsuitable; stop at 12 weeks if attacks have not fallen by at least 50%.

Pregnancy

Paracetamol → Sumatriptan Best safety data

Paracetamol first-line; sumatriptan has the best pregnancy safety data of the triptans; NSAIDs sparingly T1/T2 only, never T3. Prevention: propranolol. NEW headache or aura ≥20 weeks or postpartum → same-day maternity assessment: BP, urine protein quantification, FBC/platelets, renal function, LFTs, and assessment for pre-eclampsia/HELLP and neurological complications.

Migraine — Preventive Treatment (≥4 attacks/month or disabling)

Step 1Propranolol — start low and titrate per the SPC and local formulary. NICE CG150: discuss propranolol, topiramate or amitriptyline according to individual suitability. Avoid/caution: asthma/COPD, bradycardia, hypotension, heart block, depression, other rate-limiting medicines; toxic in overdose — take care if self-harm risk.

Step 1Amitriptyline 10–75 mg nocte (especially if coexistent depression, insomnia, or tension-type overlap). Start at 10 mg; increase by 10 mg weekly. Warn about morning sedation, dry mouth, constipation.

Step 1Topiramate 25 mg at night, increased by 25 mg weekly to 100 mg a day in two divided doses (SPC). One of three preventives NICE CG150 says to consider (propranolol, topiramate or amitriptyline; amended June 2025); needs the MHRA pregnancy prevention programme. Effective but side-effects common (cognitive slowing "dopamax", paraesthesia, weight loss). Teratogenic — MHRA 2024 Must not be used for migraine prevention in pregnancy, nor in women of childbearing potential unless Pregnancy Prevention Programme requirements are met: highly effective contraception, pregnancy test before initiation and annual risk-awareness review. Check contraceptive interactions against current MHRA/CoSRH advice. Start at 25 mg nocte.

Step 2Candesartan 8–16 mg OD — off-label, not a NICE CG150 option (BASH/local pathway; an NICE update is planned). RCT evidence. Good tolerability. Useful in patients unable to take beta-blockers or amitriptyline. Monitor renal function and BP.

Step 3CGRP-targeted therapy Specialist initiation only — after ≥3 preventive medicines have failed, not been tolerated or are unsuitable, per the relevant NICE appraisal: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and atogepant (TA973) for episodic or chronic migraine with ≥4 migraine days/month; rimegepant 75 mg alternate days (TA906) for episodic migraine only, 4–14 attacks/month.

Step 4OnabotulinumtoxinA (Botox) 155 units across 31 injection sites every 12 weeks. Specialist only. Licensed for chronic migraine (≥15 headache days/month, ≥8 of them migraine; NICE TA260). After ≥3 preventives and with medication overuse appropriately managed. PREEMPT protocol.

Tension-Type Headache — Acute

Episodic

Aspirin / Ibuprofen / Paracetamol 1st line

Ibuprofen 400 mg PO or Aspirin 500–1000 mg. Paracetamol 1 g less effective for tension-type than NSAIDs. Avoid opioids — increase MOH risk. Limit acute analgesic use to <15 days/month.

Chronic tension-type (preventive)

Amitriptyline 1st line

Amitriptyline 10–75 mg nocte. Only evidence-based pharmacological preventive for chronic tension-type. Mirtazapine 30 mg nocte if amitriptyline not tolerated. Venlafaxine 75–150 mg if depression coexists.

Cluster Headache — Acute (refer for confirmation)

Attack abort

Sumatriptan SC + O₂ First-line

Sumatriptan 6 mg SC (fastest; injectable preferred over oral). High-flow O₂ 100% at least 12 L/min via non-rebreather mask with reservoir bag for 15–20 min — order via Home Oxygen Order Form (HOOF); oxygen cannot be prescribed on an FP10. Both can be used in same attack. Oral triptans are not suitable as the principal acute treatment.

Preventive (transitional)

Verapamil + short oral prednisolone Under specialist

Verapamil 80 mg TDS initially, up to 480 mg/day (specialist-initiated). ECG before and after dose change (AV block risk). Prednisolone 60 mg reducing course to bridge while verapamil takes effect.

Medication Overuse Headache — Withdrawal

Step 1Explain and agree withdrawal plan. NICE CG150: stop all overused acute medicines abruptly, for at least 1 month; consider specialist referral for people overusing strong opioids, who may need a supervised gradual withdrawal. Expect 2–4 weeks of worsening before improvement. Give written information.

Step 2Withdrawal support: close follow-up and support. Do not routinely prescribe corticosteroid or NSAID bridge therapy; consider specialist advice in complicated withdrawal, opioid overuse, marked comorbidity, prior withdrawal failure or severe withdrawal symptoms. Strong opioids, benzodiazepines and barbiturates need a supervised taper rather than abrupt withdrawal.

Step 3Start (or continue) preventive treatment — amitriptyline and candesartan (off-label) retain efficacy even during overuse, and starting one alongside withdrawal improves completion; CGRP agents also work despite overuse. Choose by headache type; don't wait for a 'clean' month if the patient is struggling.

Step 4Specialist referral if withdrawal fails, if opioid dependence is suspected, or if coexistent psychiatric disorder complicates management.

Next steps: see Migraine · Tension-type headache · Giant cell arteritis

Triptans are 5-HT1B/1D agonists causing vasoconstriction and blocking CGRP release. They are most effective when taken at headache onset before central sensitisation develops (do not wait for severe pain). The 24-hour rule: most triptans should not be repeated within 24 hours. Use on fewer than 10 days/month to avoid MOH.

CGRP monoclonal antibodies represent a paradigm shift in migraine prevention — the first treatments specifically designed for migraine (not repurposed from other conditions). NICE appraisals (e.g. TA973 atogepant) require ≥4 migraine days/month and failure of ≥3 preventive medicines. Erenumab (Aimovig) 70 mg SC monthly is the most widely used.

Topiramate teratogenicity: Associated with oral clefts and reduced birth weight. The MHRA introduced a Pregnancy Prevention Programme in June 2024. Must not be used in women of childbearing potential unless Pregnancy Prevention Programme requirements are met (highly effective contraception, pregnancy test before starting, annual risk-awareness review). Discuss with woman before prescribing.

Lifestyle

Non-pharmacological interventions — lifestyle is treatment

Done

Encourage regular meals, consistent sleep, adequate hydration, regular activity and management of individual triggers. Avoid overly restrictive diets; base trigger avoidance on the patient's diary rather than generic exclusion lists.

Sleep regularity Target 7–9 hours at consistent times. Both too little AND too much sleep trigger migraine. "Weekend migraines" are a classic sleep-excess trigger — advise maintaining weekday routine on weekends.

Hydration Adequate hydration — no fixed target for all. Dehydration is a common and modifiable trigger. Coffee is a double-edged trigger — regular intake prevents withdrawal headache but excess worsens.

Regular meals, no skipping Blood glucose fluctuations trigger migraine. Three meals per day at consistent times. Advise carrying snacks. Identify any individual dietary triggers using the headache diary rather than generic exclusion lists.

Caffeine management Regular moderate intake is acceptable for most; no universal target. Caffeine excess AND sudden withdrawal both trigger headache. Advise gradual reduction if overusing. Caffeine-containing analgesics (Syndol, Solpadeine) increase MOH risk significantly.

Stress management Stress is the most commonly reported trigger. Psychological approaches such as CBT may help some patients. Refer via NHS Talking Therapies if available. Mindfulness-Based Stress Reduction (MBSR) has RCT evidence. GP wellness prescription.

Regular aerobic exercise Regular aerobic activity (walking, swimming, cycling) is encouraged. Start low — intense exercise can trigger attacks initially. Build up gradually over 6–8 weeks.

Screen and posture hygiene Prolonged screen use, poor ergonomics, and forward head posture are key contributors to tension-type and cervicogenic headache. Advise 20-20-20 rule (every 20 min, look 20 feet away for 20 seconds). Workstation assessment referral.

Alcohol Alcohol (particularly red wine, beer) is a common trigger. Even small amounts can trigger cluster attacks within 1 hour of ingestion. Advise alcohol diary. AUDIT score — address alcohol misuse as separate problem if detected.

OCP and hormonal factors Migraine with aura is a contraindication to combined hormonal contraception (UKMEC 4) due to increased stroke risk. Individualise alternatives — progestogen-only pill, implant, LNG-IUS, copper IUD or depot medroxyprogesterone — by patient preference and reproductive plans. Perimenopause commonly worsens migraine; any HRT decision needs menopause-specific assessment (migraine with aura does not automatically preclude transdermal HRT).

Weight management Obesity is associated with more frequent migraine and is a risk factor for IIH. Weight loss may help. Refer to structured weight management programme where available. Topiramate has weight-loss side effect that can be advantageous.

Exercise: regular aerobic activity is low-risk, has cardiovascular, metabolic and psychological benefits, and may help some people with migraine; evidence that it matches drug prophylaxis is limited.

Psychological therapies such as CBT may help some patients with chronic headache by addressing stress, catastrophising and pain coping; they complement rather than replace other treatment.

OCP + migraine with aura: Migraine with aura is an independent risk factor for ischaemic stroke, and combined hormonal contraception further increases this risk. UKMEC category 4 (contraindicated). Always ask about aura before prescribing hormonal contraception.

Safety

Follow-up, monitoring, and safety-netting

Done

Safety-net every patient with a clear plan. Document the safety-net advice given. Follow-up intervals depend on treatment complexity and diagnosis confidence.

4–6 weeks First review

Review headache diary. Assess acute medication frequency (screen for emerging MOH: triptans, opioids, ergots or combination analgesics ≥10 days/month; paracetamol, aspirin or NSAIDs ≥15 days/month). Check preventive medication tolerability. Adjust dose. Reinforce lifestyle changes.

8–12 weeks Preventive review

Assess preventive efficacy (target 50% reduction in headache days). If no improvement, check adherence and correct diagnosis before escalating. Consider dose increase or switch. Review triggers from diary.

6 months Stability review

Consider stepping down preventive if headache-free for 6 months. Gradual withdrawal over 2–3 months. Review QoL impact (MIDAS or HIT-6 questionnaire). Re-evaluate OCP, hormonal factors in women.

GCA monitoring

If on prednisolone for GCA: follow the rheumatology/local fast-track GCA protocol. Steroid adverse-effect prevention and monitoring (bone protection, glucose, BP, weight, cataracts); inflammatory-marker monitoring frequency per specialist plan. Taper is individualised to symptoms, inflammatory markers and the specialist plan, frequently lasting 12–24 months.

Verapamil monitoring

12-lead ECG before starting and after each dose increase (PR interval: stop if >240 ms). LFTs and FBC at 6 months. Cluster headache: continue for full cluster period + 2 weeks, then taper.

Topiramate monitoring

Pregnancy Prevention Programme: highly effective contraception and annual risk-awareness review. Kidney stones (increase fluid intake). Cognitive effects — use word-finding test. Bicarbonate if metabolic acidosis suspected (anorexia, fatigue, hyperventilation).

Safety-net 999

New thunderclap headache or sudden severe onset. Any new focal neurological deficit. Neck stiffness + fever ± rash. Severe headache with visual loss. Reduced consciousness. Written safety-net — patient can show to paramedics.

Safety-net same-day

New headache in someone with cancer / HIV / immunosuppression. Headache worsening despite treatment. New scalp tenderness / jaw claudication in patient >50. Postural worsening (flat/standing) of headache. New visual symptoms with headache. New or severe headache in pregnancy or postpartum (same-day maternity assessment).

Tools for monitoring

MIDAS (Migraine Disability Assessment): validates treatment response, supports referral. HIT-6 (Headache Impact Test): scored 1–78; >56 = severe impact. PHQ-9 if depression screen positive. Headache diary ongoing throughout treatment.

Medication overuse headache develops silently — most patients are unaware they are overusing. Review headache diaries for analgesic frequency at every appointment, not just headache frequency. Once MOH is established, preventives are ineffective until overuse is stopped.

GCA relapse rate is substantial during prednisolone taper. Patients must know to contact GP immediately if jaw claudication or visual symptoms recur — even on treatment. Visual loss is irreversible once established.

MIDAS score is a validated disability score — know how to use and interpret it. Score >21 = grade IV (severe disability) and supports preventive treatment and specialist referral. It is also used to demonstrate treatment response to commissioners and for CGRP criteria.

Educational use only. Pathway based on: NICE CG150 (Headaches in over 12s, 2012, updated June 2025), NICE NG12 (Suspected cancer, updated April 2026), ICHD-3 (International Classification of Headache Disorders 3rd edition), British Association for the Study of Headache (BASH) guidelines, NHS England CGRP prescribing guidance, MHRA topiramate Pregnancy Prevention Programme (Drug Safety Update, June 2024), BSR giant cell arteritis guideline (2020), NICE NG228 (subarachnoid haemorrhage), NICE NG127 (suspected neurological conditions), NICE TA919 and TA906 (rimegepant), NICE TA973 (atogepant), NICE TA260 (botulinum toxin A), NICE TA518 (tocilizumab for giant cell arteritis). Always adapt to individual patient context, local formulary, and the current versions of the guidelines listed above; check doses in the SPC and your local formulary.