Headache Classification & Management: NICE Guidelines & Local Formulary, Study Guides, Projects, Research of Pathology

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The international classification of headache disorders states that there are three categorises of headache : Primary Headache Secondary Headache Neuralgias and other headaches Primary headaches are headaches which are not associated with other underlying conditions whereas Secondary headaches are hea daches that occur as a result of an underlying local or systemic pathology e.g. Trauma or injury, giant cell arteritis. The majority of headaches (approx. 90%) are Primary headaches (i.e. migraine, tension type headache or cluster headache) The following Clinical Knowledge Summaries (CKS) have been published by NICE: Headache Assessment Migraine Tension Type Headache Cluster Headache Medication overuse headache. Each individual CKS provide comprehensive information on each area including background information, prognosis, diagnosis, when to refer, acute treatment, preventative treatment, follow up, special populations e.g. pregnancy and breastfeeding. Each CKS has easy to use navigation tabs linking to the specific sections (See below for links to the individual CKS documents)

Take a detailed symptom and drug history (Including OTC medications and herbal medications) When considering the possible diagnosis and determining whether there is a need for referral to a Specialist - Follow the CKS headache assessment guideline

Patient presents with headache

If a diagnosis of a primary headache is made, see the relevant CKS below for detailed information including general advice on lifestyle changes, advice on acute treatment, preventative treatment, treatment of special populations e.g. pregnancy etc. Migraine (Updated April 19) (Includes treatment of menstrual migraine)

Tension Headache

Cluster headache

Medication Overuse Headache

If patient does not respond to the treatment or if there is clinical doubt, contact specialist (use Advice & Guidance on Electronic Referral Service)

https://cks.nice.org.uk/headache-assessment:

https://cks.nice.org.uk/migraine

https://cks.nice.org.uk/headache-tension-type

https://cks.nice.org.uk/headache-cluster

https://cks.nice.org.uk/headache-medication-overuse

click here

click here

For formulary advice on choice of triptans -

For local amendments to the individual CKS treatment options listed above -

Bedfordshire CCG Date Created: June 2019 Date of Review: June 2021

Diagnosis and Management of Primary Headache in Adults

Triptans – Choice of Agents

Migraines

Local joint formulary choices of oral triptans are sumatriptan, zolmitriptan rizatriptan and naratriptan, all four have similar effectiveness. Oral sumatriptan is an acceptable first line choice in the majority of patients When making the choice of which oral triptan to prescribe, clinicians should take into account individual patient factors/presence of other co-morbidities and patient preference The response of an individual to a specific drug is unpredictable and evidence shows that if a patient has a poor response to one triptan another triptan should be tried in subsequent attacks

Other Points to consider:

Naratriptan has a slower onset of action compared with sumatriptan and zolmitriptan but has a better tolerability profile Zolmitriptan orodispersible sugar free tablets may be an option for patients who have difficulty swallowing tablets* If vomiting/nausea is problematic and limits the use of oral agents, consider trying intranasal zolmitriptan or subcutaneous sumatriptan (Do not use intranasal sumatriptan if vomiting is problematic as its bioavailability depends largely on ingestion )

Pure menstrual and menstrual-related migraine – Preventative Treatment

NICE CKS recommendation: for women with predictable menstrual-related migraine that do not respond adequately to lifestyle measures and standard acute treatment and where there are no contraindications consider treatment (off-label use) with: Frovatriptan (2.5 mg twice daily) on the days migraine is expected or from two days before until three days after bleeding starts or Zolmitriptan (2.5 mg twice or three times daily) on the days migraine is expected or from two days before until three days after bleeding starts Frovatriptan is a restricted use item – Frovatriptan should only be prescribed for the prevention of menstrual related migraine and should not be prescribed for the acute treatment of migraine (local joint formulary decision)

Formulary Choices:

Triptan Formulations available On set of action/Duration of action (approximate times)

Sumatriptan Oral (50mg / 100mg tablets) 30 minutes s/c (6mg injection) 15 minutes

Zolmitriptan Oral 2.5mg tablets (also available as Within 1 hour orodispersible sugar free tablets*)

Rizatriptan Oral 5mg/10mg tablets (also available as 30 minutes orodispersible sugar free tablets*)

Naratriptan Oral 2.5mg tablets 1-3 hours: long duration of action

Frovatriptan Oral 2.5mg tablets 3 hours: longer duration of action (t½ = 24hrs)