Management of primary headaches in the over 12s
In the management of all headache disorders consider the use of a headache diary. This will help the understanding of the frequency, duration and severity of the attacks, the effectiveness of interventions, the presence or absence of trigger factors, may reveal a menstrual related pattern and can act as a basis for discussion of the impact of the headache on the individual.
As part of the management a diagnosis should be made and reassurance of the patient that other pathology has been excluded. Written information or links to support web sites may be given (see resources section). Management options should be discussed and the risk of medication overuse headache should also be pointed out.
Tension type headache
NICE recommend treatment with aspirin, Paracetamol or an NSAID and advise that codeine is not used. For the prophylaxis of chronic tension type headache they recommend consideration of a course of acupuncture (10 sessions).
Migraine with or without aura
The treatment of migraine should be tailored to the individual and both acute and prophylactic treatment considered in conjunction with the patient. Acute treatment for migraine may be monotherapy with an oral triptan, (nasal in the 12-17yr olds), Aspirin 900mg, Paracetamol or an NSAID. When considering dual therapy an oral triptan and Paracetamol or an oral triptan with an NSAID should be used.
Anti-emetics may be added (metoclopramide or prochloperazine) even in the absence of nausea and vomiting. If oral treatment is ineffective non-oral routes of administration should be considered. Ergots and opioids should not be used.
If trigger factors can be identified and modified or avoided this should be carried out (again a diary may be useful here)
Where prophylactic treatment is needed propranolol or topramate should be offered first line with amitriptyline to be considered in the suitable patient. (Topramate carries a risk of foetal abnormalities and impairs the effectiveness of hormonal contraceptives.)
Gabapentin has no role in the prophylaxis of migraine however NICE advises that acupuncture may help as may Riboflavin 400mg daily
Refractory menstrual migraine may be treated with frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) on the days migraine is expected.
During pregnancy Paracetamol is the drug of choice although NICE suggests that both triptans and NSAIDs can be used after a discussion of the risks associated with their use. The full NICE CKS on pregnancy can be accessed here
Cluster headaches
Cluster headaches are fortunately rare and as such seen infrequently in primary care. On the first presentation of cluster headache the GP should obtain advice from a headache specialist as to the need for imaging. The first line treatments are 100% oxygen (12L min) and parenteral triptan. NICE advise against the use of Paracetamol, NSAIDs, Opiods, Ergots of oral triptans. Verapamil may be considered for prophylactic treatment but high doses are usually required and GPs may need to seek specialist advice on the dosing and monitoring of this. Specialist involvement is needed in unresponsive cases and pregnancy.
Medication overuse headache
The treatment of medication overuse headache is by abrupt withdrawal of the causative agent. The headaches can take a month or more to resolve and the patient should be reviewed to confirm resolution 6-8 weeks after withdrawal. If an underlying primary headache condition (often migraine) is present then prophylaxis of that condition should be offered.