Follow NICE guidelines to quickly master the diagnosis and treatment of primary headache

*Only for medical professionals for reference A series of guidelines issued by NICE
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NICE recently updated its guidelines for the diagnosis and management of headaches in people 12 years and older (Headaches in over 12s: diagnosis and management)
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The guideline is aimed at the evaluation of headache patients, especially the diagnosis, treatment and management of three types of primary headache and medication overuse headache are recommended
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01 The following 13+4 conditions are encountered in the evaluation of headache patients, and further examination and/or referral of the patient should be considered (Table 1), because these conditions may be secondary headaches and should be diagnosed and treated as secondary headaches
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The content is detailed, everyone read it carefully and treat it with caution
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Table 1.
Headache assessment, consideration for further testing and/or referral For patients with primary headache, consider using a headache diary to aid in diagnosis
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A headache diary can also help monitor the effects of headache treatment
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The headache diary should allow the patient to keep track of the following 5 points for at least 8 weeks: 1) headache frequency, duration, severity 2) any accompanying symptoms 3) all prescription and over-the-counter medications taken to relieve headache 4) possible exacerbating factors 5) headache Relationship with menstruation (female patients) 02 Diagnosis of the three major primary headaches (tension-type headache, migraine, cluster headache), please refer to the characteristics given in Table 2
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Table 2.
Top 3 primary headache characteristics Chronic headache 1) The standard duration of both chronic migraine and chronic tension-type headache is that the headache occurs 15 days or more per month and lasts for more than 3 months
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Both episodic migraine and episodic tension-type headache are headaches less than 15 days per month
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2) Chronic migraine and chronic tension-type headache often overlap, and chronic migraine is diagnosed if features of migraine are present
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3) Episodic cluster headache attacks occur 1 to 8 times every other day, and the headache remission period exceeds 1 month
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Chronic cluster headache is defined as one to eight headache attacks every other day within a 12-month period, and the headache remission period does not exceed one month
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Menstrual-Associated Migraine Menstrual-associated migraine should be suspected in women with overt migraines presenting 2 days before or 3 days after the onset of menstruation for at least 3 consecutive menstrual cycles
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The following drugs have been used for 3 months or more, and patients should be alert to drug overuse headache if their headache develops or worsens: 1) triptans, opioids, ergots or combinations, 10 days or more per month; 2) paracetamol Aminophenol, aspirin, or nonsteroidal anti-inflammatory drugs, alone or in combination, 15 or more days per month
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03Treatment management 1) All headache patients should consider using a headache diary to record headache frequency, intensity and duration in order to monitor the effectiveness of treatment and better communicate with the patient
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2) One of the 13+4 conditions in the above assessment should be considered for further examination or referral
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3) Imaging should not be prescribed for patients with tension-type headache, migraine, cluster headache, or medication-overuse headache just for reassurance
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4) Due to the possibility of Reye's syndrome, medicines containing aspirin should not be given to patients under the age of 16
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Tension-type headache ■ Treatment of acute attacks: Consider aspirin, acetaminophen, or NSAIDs, taking into account patient preference, comorbidities, and side effects
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Do not use opioids in the treatment of an acute attack of tension-type headache
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■ Preventive treatment: Consider acupuncture for 5-8 weeks in patients with chronic tension-type headache
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Migraine with or without aura Treatment of acute attacks: 1) Administer oral triptans + NSAIDs, or oral triptans + acetaminophen combination therapy, while paying attention to patient preference, comorbidities and side effects
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Nasal sprays may be considered for triptans in patients 12-17 years of age
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In the UK, triptans are used off-label for use under the age of 18, with the exception of sumatriptan nasal spray
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2) If the patient prefers a single drug, consider one of oral triptans, NSAIDs, aspirin (900 mg), or acetaminophen
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If a patient does not respond well initially with one triptan, other triptans may be considered
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3) Consider adding an antiemetic to the acute treatment of migraine even if the patient has no symptoms of nausea and vomiting
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However, pay attention to the special warnings and precautions for the use of metoclopramide or prochlorperazine, and comprehensively analyze the benefits and risks of the medication
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4) Do not prescribe ergots and opioids to migraine sufferers
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5) Ineffective or intolerable to oral acute treatment drugs (or nasal spray for 12-17 years old), consider non-oral metoclopramide or prochlorperazine; if oral metoclopramide or prochlorperazine have been used , consider adding naïve non-oral NSAIDs or triptans
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6) Pregnant women with migraine can be given acetaminophen to treat acute attacks
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The use of triptans and NSAIDs requires consideration of the patient's treatment needs, as well as the benefits and risks associated with their use
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■ Preventive therapy: 1) First discuss the benefits and risks of preventive therapy with the patient, considering the impact of headaches on life, as well as patient preferences, comorbidities, and side effects
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2) When giving topiramate and propranolol to prevent migraine, it is necessary to discuss the benefits and risks of the drug with the patient, and inform that topiramate has the risk of teratogenicity and can also reduce the contraceptive effect of hormonal contraceptives; propranolol may increase depression Risk of self-harm in patients with comorbid migraine and migraine
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Amitriptyline therapy may also be considered
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In the UK, topiramate for the preventive treatment of migraine in children and adolescents and amitriptyline for the preventive treatment of migraine are both off-label use
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3) Do not use gabapentin for migraine preventive treatment
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4) If topiramate and propranolol are inappropriate or ineffective, 5-8 weeks of acupuncture treatment can be considered
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5) After 6 months of starting prophylactic treatment, the need for continued treatment should be reassessed
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6) Inform patients that oral intake of 400 mg of vitamin B2 daily may reduce migraine frequency and severity in some individuals
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But this is for off-label use, which patients can obtain from dietary supplements
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7) For female patients with migraine with aura, do not routinely give combined hormonal contraceptives for contraception
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8) In women with menstrual-related migraine, standard acute treatment is not effective, and folic acid (2.
5 mg twice daily) or zolmitriptan (2.
5 mg twice daily or three times a day)
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9) During pregnancy, preventive treatment of migraine should be consulted with a specialist
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Cluster headache ■ Treatment of acute attacks: 1) For patients with cluster headache who have a first headache attack, the general practitioner should discuss with a headache specialist or neurologist whether imaging studies are necessary
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2) Give oxygen inhalation therapy according to the following requirements: Oxygen concentration: 100%
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Oxygen flow: at least 12 liters per minute
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Oxygen inhalation device: non-rebreathing mask and air bag
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3) Subcutaneous or intranasal triptans can be used for treatment, and the dosage should be calculated according to the previous episodes of medication to ensure that the dose is sufficient, but it should be within the maximum daily dose range of the instructions
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Note that subcutaneous use of triptans in the UK under the age of 18 is off-label use
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4) Do not give acetaminophen, NSAIDs, opioids, ergots, or oral triptans to patients with cluster headaches
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■ Prophylactic treatment: 1) Consider verapamil prophylactic treatment for cluster headache
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If you are unfamiliar with how to use it, you should consult a specialist, including for ECG monitoring
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In the UK, verapamil is used off-label for cluster headache prophylaxis
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2) If verapamil is ineffective, or treatment during pregnancy, relevant experts should be consulted
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Medication Overuse Headache 1) Inform patients that the treatment for medication overuse headache is to discontinue the overused medication
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2) It is recommended that patients stop all overused drugs for at least 1 month, and stop directly rather than gradually
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3) Inform patients that headache symptoms may worsen in the short term, which may be related to drug withdrawal, and follow up closely according to the needs of patients
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4) In addition to discontinuation, consider prophylactic treatment for their primary headache
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5) Discontinuation usually does not require hospitalization
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Referral or hospitalization for discontinuation may be considered in those patients on potent opioids or in those with comorbidities, or in patients who have failed prior discontinuation
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6) Evaluate the diagnosis of medication overuse headache 4-8 weeks after discontinuation of the drug and further manage it
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04 Doctor-patient communication Finally, for the management of migraine, doctor-patient communication is also very important.
Don’t forget to provide this information to headache patients: 1) Tell the patient about the diagnosis of headache, treatment options and explain, and remind the patient of headache Illness can have some impact on patients and their families
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2) Provide patients with medical information about headaches, including where to go for treatment, either verbally or in paper form
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3) For patients taking medication for acute headache attacks, explain the risk of medication overuse headache to the patient
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  Headache is a common clinical manifestation, which can be divided into primary headache and secondary headache according to its etiology
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The NICE Guidelines for the Diagnosis and Management of Headaches in the UK for People 12 Years and Over (NICE Headache Guidelines) cover the three most common primary headaches and medication overuse headaches, published in September 2012 and updated again in December 2021
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In this revision, the recommendation of metoclopramide and prochlorperazine when acute treatment is ineffective or intolerable is changed from “offer” to “consider”; in the description of migraine prevention treatment, it is added that “topiramate should be used when using topiramate”.
In-depth discussion with patients about the benefits and risks of medication"; added a reminder that propranolol increases the risk of self-harm in patients with depressive comorbidities
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In the NICE headache guidelines, episodic cluster headache requires a remission period of more than 1 month, and chronic cluster headache has no remission period or a remission period of less than 1 month.
The NICE headache guidelines for the diagnosis of chronic migraine are not detailed
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For clinical diagnosis of such diseases, especially in clinical research, it is recommended to use the diagnostic criteria of ICHD-3
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The NICE headache guidelines clearly state that oral triptans should not be given to patients with cluster headaches
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However, we have found in clinical practice that although the onset of action is slightly slower than that of nasal sprays, oral triptans can significantly improve headache symptoms in many patients
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In the current situation of insufficient dosage forms of triptans in China, despite the off-label use, oral triptans may be a suitable choice for the helpless acute treatment of cluster headache
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Epidemiological surveys show that the annual prevalence of primary headache in China is 23.
8%, and there are problems such as insufficient awareness and irregular diagnosis and treatment, which seriously affect the quality of life and social economy of patients
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The NICE headache guideline emphasizes the importance of doctor-patient communication.
It not only provides professional physicians with very practical recommendations for the assessment, diagnosis, and treatment management of headache patients, but is highly maneuverable and worthy of our attention and study.
Expert knowledge of headache sufferers to read
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Expert Profile Wang Hebo Chief Physician and Professor of Neurology Department of Hebei Provincial People's Hospital
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Doctor of Medicine, doctoral tutor
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Member of the Pain and Sensory Impairment Special Committee of the Chinese Medical Doctor Association, Vice Chairman of the Headache and Sensory Impairment Professional Committee of the Chinese Research Hospital Association 1] NICE.
Headaches in over 12s:diagnosis and management.
Link: https:// First release of the text: Neurology Channel in the medical community Editor-in-Chief of Neurology: Mr.
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