Headache – SW London Integrated Medicines Optimisation Committee

This guideline is aimed at primary care clinicians in NHS SWL. It outlines the headache referral and management pathway for adults (18 years or older) and signposts to national and local guidance where appropriate.

Recommendations are based on NICE Guidance: Headaches in over 12s: diagnosis and management, BASH headache management guidelines and NICE Clinical Knowledge Summaries.

This guidance has been developed for use in adult patients in SWL and 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.

Clinicians are reminded to pause and consider secondary causes of headaches. The visual summary flow chart contains the pathway for headache referral and management, along with headache amber and red flags.

Assessment and diagnosis

This headache referral and management pathway and NICE CKS Headache – assessment provides information on how to assess a patient presenting with headache to accurately diagnosis the type of headache. This includes history taking, examination and arranging investigations if necessary.
Assessment should include exclusion of red and amber flags suggesting a potentially serious underlying cause, requiring emergency admission or urgent specialist referral.
Consider medication overuse headache, which is defined as ‘Headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of one or more drugs that can be taken for acute and/or symptomatic treatment of headache, for more than 3 months.’ See NICE CKS Headache – medication overuse for more information.
At first Primary Care review, give headache diary to inform further care if needed.
Less common benign diagnoses to consider:
- Cervicogenic headache (over diagnosed)
- Primary stabbing headache
- Trigeminal neuralgia
- Primary sex headache
If diagnosis is still unclear after second Primary Care review, consider electronic advice discussion if specific query or referral to local neurology headache services.

Management of Tension Type Headache

See NICE CKS Headache – tension-type for more information.
If headache occurs less than 8 days per month, advise to take simple analgesia and warn about medication overuse.
If headache occurs more than 8 days per month, consider Amitriptyline. Refer to BNF and SmPC for full product information. Reconsider diagnosis (?migraine).

Management of Cluster Headaches (new diagnosis or relapse)

See NICE CKS Headache – Cluster for more information.
Refer to Acute Neurology Clinic / Headache Clinic for urgent review.
Signpost patients to OUCH(UK) – The Cluster Headache Charity | Support for Sufferers & their Families

Management of Migraine

For all patients offer lifestyle advice, trigger factors, review if on combined oral contraceptive, headache diary, warn about medication overuse. Prescribing decisions should be made with reference to the patient’s current clinical situation and their future plans (e.g. pregnancy or contraception). Further information:

Acute treatment of migraine

Low frequency

Less than 4 days per month:

First line treatment: Simple analgesia and anti-emetic
Second line treatment: Triptan and analgesia – see ‘Primary care acute migraine prescribing guidelines for use in adults’

High frequency

More than 4 days per month:

Offer acute treatment as per ‘Primary care acute migraine prescribing guidelines for use in adults’
Start preventive treatment (prophylaxis).
Refer to the headache clinic if failed 2 or 3 oral preventive medicines (defined as lack of a clinically meaningful response, intolerance or have contraindications to treatment). Oral preventive treatments should have been given at maximum tolerated doses for a minimum of 3 months. If referral is made after two preventive medicines failed, third preventive medicine should be tried while awaiting headache clinic appointment.
See SWL Episodic and Chronic Migraine Drug Pathways for information about high cost drugs.

Chronic Migraine

More than 15 days per month of any headache (migrainous or not):

Exclude medication overuse
Start preventive treatment.
Refer to the headache clinic if failed 2 or 3 oral preventive medicines (defined as lack of a clinically meaningful response, intolerance or have contraindications to treatment). Oral preventive treatments should have been given at maximum tolerated doses for a minimum of 3 months. If referral made after two preventive medicines failed, third preventive medicine should be tried while awaiting Headache Clinic appointment.
See SWL Episodic and Chronic Migraine Drug Pathways for information about high cost drugs.
SWL Regional Headache Referral form

Prevention of migraine

Consider preventive treatment in adults who are not pregnant or breastfeeding if:
- Attacks are frequent or prolonged and severe despite appropriate acute treatment.
- The person is at risk of medication overuse headache.
Do not initiate preventive treatment in primary care for women who are pregnant or breastfeeding. Seek specialist advice if preventive treatment for migraine is needed during pregnancy or if planning pregnancy, as many preventive drugs have limited evidence of safety or are contraindicated in these groups.
When selecting a preventive treatment, consider the patient’s other co-morbidities, whether they have child-bearing potential, previous treatment, personal preference, drug interactions and side effect profiles of the various treatments.
Drug treatment should be initiated at low dose and titrated according to efficacy and tolerability.
Treatments may take up to 6 weeks to provide a benefit.
Arrange follow up to monitor effectiveness, titrate dose and assess for adverse effects. A headache diary may help evaluate response to treatment.
After 6 to12 months of successful therapy, review the need for continuing preventive treatment and consider gradual drug withdrawal.
See NICE CKS: Drugs for the prevention of migraine for further information.
The SWL Episodic and Chronic Migraine Drug Pathways has information on the pathway for high cost drugs for episodic and chronic migraine.

Preventive treatment

Recommended preventive treatment options for migraine (listed in alphabetical order) include:

Amitriptyline (RAG rating: Green)

Start: 10mg every night, increase dose if tolerated in steps of 10 to 25mg every 7 days in 1 or 2 divided doses.
Target: 50mg every night.
Max: 100mg daily (Maximum per dose is 75mg. Doses above 75mg daily should be taken in 2 divided doses).
Doses above 75mg should be used with caution in the elderly and in patients with cardiovascular disease.
Amitriptyline can be taken during pregnancy for migraine prevention if it is needed. The clinician should have a discussion about the benefits and risks with the patient. See Pregnancy, breastfeeding and fertility while taking amitriptyline for pain and migraine – NHS for further information.
Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.

Candesartan (RAG rating: Green)

Migraine prophylaxis is an approved, off-label indication.
Start: 4mg every night, increase dose if tolerated by 4mg every week.
Target: 16mg every night.
In exceptional cases, if partial response to 16mg dose, consider increasing further by 4mg every week. Max: 32mg every night.
Monitor renal function at baseline, 1 to 2 weeks after starting candesartan, after each increase in dose and regularly throughout treatment.
The use of angiotensin II receptor antagonists is not recommended during the first trimester of pregnancy and contraindicated during the second and third trimesters of pregnancy.
Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.

Propranolol(RAG rating: Green)

Start: 40mg every night, increase dose if tolerated by 40mg every week.
Target: 80mg twice daily.
Max: 120mg twice daily.
Refer to the BNF and SmPC for full product information. including contraindications, cautions, drug interactions and side effects.
Avoid in pregnancy.
Note: HSSIB review (2020) Potential under-recognised risk of harm from the use of propranolol

Topiramate

New regulatory measures have been introduced because there is evidence that the use of topiramate during pregnancy is associated with significant harm to the unborn child.
The use of topiramate is now contraindicated:
- In pregnancy for prophylaxis of migraine
- In women of childbearing potential unless the conditions of the Pregnancy Prevention Programme (PPP) are fulfilled.
- Refer to MHRA Topiramate safety measures for further information and support material.
New patients:
- For licensed indication (e.g. migraine prophylaxis) and conditions of PPP met: RAG rating Amber 1: The GP can initiate topiramate following recommendation by a specialist via Advice and Guidance. It is the responsibility of the initiating clinician to ensure that the requirements of the PPP are fulfilled including ensuring suitable contraception is in place. The initiating clinician must complete the Risk Awareness Form (RAF) for migraine on initiation and annually thereafter. Please note: If the GP initiates treatment under Amber 1 following Advice and Guidance, it is the responsibility of the GP to ensure the requirements of the PPP are met and RAF is completed.
- For licensed indication and conditions of PPP are not met (even when informed choice by patients) Note: This makes the use unlicensed: RAG rating Red.

Existing patients:
- Prescribing continues in primary care following pre-existing arrangements. Refer to topiramate flow diagram which outlines how to manage existing female patients of childbearing potential prescribed topiramate in primary care on GP Teamnet.
- If the patient has been managed in primary care for a significant period of time, then the primary care healthcare professional (HCP) will complete the PPP and RAF (and at annual review), if it is within their competency. If the patient has a complex medical history, then the primary care HCP should seek advice from the specialist.
- Dose as per BNF
- Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.

Valproate

Refer to MHRA alert female and MHRA alert male for information on the new regulatory requirements.
- New patients (male and female):
For unlicensed indications (as defined by SWL Valproate Policy e.g. migraine prophylaxis): RAG ratingRed.
Existing female patients (of child bearing potential),RAG ratingAmber 2, who are taking valproate for prophylaxis of migraine must be referred back to the specialist for completion of an Annual Risk Acknowledgement Form. Annual ARAF reviews must be completed by the initiating specialist.
Existing male patients,RAG rating Amber 2:
- See Advice for male patients on valproate to use contraception and visual risk communication diagram to be used by a healthcare professional when counselling on the risks.
- If there is any change in circumstances such as a male patient who is planning a family in the next year, the patient must be referred to a specialist to discuss alternative treatment options. The GP must advise the patient not to stop taking valproate whilst waiting for a review with their specialist.
Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.

References

V1.2 Approved by Integrated Medicines Optimisation Committee (IMOC) January 2025