NICE｜The guidelines for diagnosis and treatment of headaches are updated after 10 years!

Headache is a common disease that is difficult to deal with, which seriously affects the health of patients and causes a huge social burden

Figure 1 Diagnosis of tension-type headache, migraine, and cluster headache

Menstrual-related migraine: Suspected menstrual-related migraine in women from 2 days before menstruation to 3 days after menstruation in three consecutive menstrual cycles (at least two of them)

• Taking triptans, opioids, ergots, or combination pain relievers 10 or more days per month;

• Acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs or NSAIDs), either alone or in any combination, 15 days or more per month
  
  2.
  
  【Acute treatment】 
  • Treatment with a combination of oral triptans and NSAIDs or oral triptans and acetaminophen should take into account the individual patient's circumstances, the risk of complications and adverse events
    .
    In patients 12 to 17 years of age, nasal triptans are preferred over oral triptans
    .
    
• Treatment with a combination of oral triptans and NSAIDs or oral triptans and acetaminophen should take into account the individual patient's circumstances, the risk of complications and adverse events
  .
  In patients 12 to 17 years of age, nasal triptans are preferred over oral triptans
  .
  
Treatment with a combination of oral triptans and NSAIDs or oral triptans and acetaminophen should take into account the individual patient's circumstances, the risk of complications and adverse events
.
Patients 12 to 17 years of age, and patients 12 to 17 years of age, are given priority to nasal triptans over oral triptans
.

• For patients who prefer to take only one drug, consider oral triptans, NSAIDs, aspirin, or acetaminophen
  .
  
• For patients who prefer to take only one drug, consider oral triptans, NSAIDs, aspirin, or acetaminophen
  .
  
For patients who prefer to take only one drug, consider oral triptans, NSAIDs, aspirin, or acetaminophen
.

• In other acute treatments of migraine, antiemetics may be considered even in the absence of nausea and vomiting
  .
  
• In other acute treatments of migraine, antiemetics may be considered even in the absence of nausea and vomiting
  .
  
In other acute treatments of migraine, antiemetics may be considered even in the absence of nausea and vomiting
.

• Ergot or opioids are not recommended
  .
  
• Ergot or opioids are not recommended
  .
  
Ergot or opioids are not recommended
.

• For those in whom oral formulations (or nasal formulations for young adults 12 to 17 years of age) are ineffective or intolerable in acute migraine treatment: Consider nonoral formulations of metoclopramide or prochlorperazine; if not previously tried nonoral formulations Oral NSAIDs or triptans may also be considered
  .
  
• For those in whom oral formulations (or nasal formulations for young adults 12 to 17 years of age) are ineffective or intolerable in acute migraine treatment: Consider nonoral formulations of metoclopramide or prochlorperazine; if not previously tried nonoral formulations Oral NSAIDs or triptans may also be considered
  .
  
For those in whom oral formulations (or nasal formulations for young adults 12 to 17 years of age) are ineffective or intolerable in acute migraine treatment: Consider nonoral formulations of metoclopramide or prochlorperazine; if not previously tried nonoral formulations Oral NSAIDs or triptans may also be considered
.

• Pay attention to the special warnings and precautions in the metoclopramide and prochlorperazine product inserts and discuss their benefits and risks with the patient (or their parents or caregivers, as the case may be)
  .
  
• Pay attention to the special warnings and precautions in the metoclopramide and prochlorperazine product inserts and discuss their benefits and risks with the patient (or their parents or caregivers, as the case may be)
  .
  
Pay attention to the special warnings and precautions in the metoclopramide and prochlorperazine product inserts and discuss their benefits and risks with the patient (or their parents or caregivers, as the case may be)
.
【Prophylactic treatment】 
• Depending on individual patient circumstances, comorbidities, differences in the risk of adverse events, and the impact of headache on quality of life , topiramate or propranolol may be considered , but topiramate may increase the risk of fetal malformations and reduce the efficacy of hormonal contraceptives
  .
  Therefore, women and girls of childbearing potential who are treated with topiramate should ensure appropriate contraception (eg, use of medroxyprogesterone acetate reserve injections, intrauterine contraception, or hormonal contraception combined with a barrier method)
  .
  
• Depending on individual patient circumstances, comorbidities, differences in the risk of adverse events, and the impact of headache on quality of life , topiramate or propranolol may be considered , but topiramate may increase the risk of fetal malformations and reduce the efficacy of hormonal contraceptives
  .
  Therefore, women and girls of childbearing potential who are treated with topiramate should ensure appropriate contraception (eg, use of medroxyprogesterone acetate reserve injections, intrauterine contraception, or hormonal contraception combined with a barrier method)
  .
  
Depending on the individual patient, comorbidities, differences in the risk of adverse events, and the impact of headache on quality of life, quality of life topiramate or propranolol may be considered , but topiramate may cause an increased risk of fetal malformations, Reduced Efficacy of Hormonal Contraceptives Topiramate is associated with an increased risk of fetal malformations and reduced efficacy of hormonal contraceptives
.
Therefore, women and girls of childbearing potential, if taking
.
Topiramate treatment, ensuring that appropriate contraception is provided .



• The use of propranolol in patients with comorbid depression and migraine may increase the risk of self-harm, therefore, caution should be exercised when prescribing propranolol
  .
  
• The use of propranolol in patients with comorbid depression and migraine may increase the risk of self-harm, therefore, caution should be exercised when prescribing propranolol
  .
  
The use of propranolol in patients with comorbid depression and migraine may increase the risk of self-harm, therefore, caution should be exercised when prescribing propranolol
.

• Amitriptyline may be considered based on individual patient circumstances, risk of complications and adverse events
  .
  
• Amitriptyline may be considered based on individual patient circumstances, risk of complications and adverse events
  .
  
Amitriptyline may be considered based on individual patient circumstances, risk of complications and adverse events
.

• Gabapentin is not recommended
  .
  
• Gabapentin is not recommended
  .
  
Gabapentin is not recommended
.
Gabapentin is not recommended
.

• If neither topiramate nor propranolol is suitable or effective, up to 10 courses of acupuncture may be considered within 5 to 8 weeks, depending on individual patient circumstances, complications, and risk of adverse events
  .
  
• If neither topiramate nor propranolol is suitable or effective, up to 10 courses of acupuncture may be considered within 5 to 8 weeks, depending on individual patient circumstances, complications, and risk of adverse events
  .
  
If neither topiramate nor propranolol is suitable or effective, up to 10 courses of acupuncture may be considered within 5 to 8 weeks, depending on individual patient circumstances, complications, and risk of adverse events
.

• For patients already on another prophylactic regimen, their migraine is well controlled and current treatment can be continued as needed
  .
  
• For patients already on another prophylactic regimen, their migraine is well controlled and current treatment can be continued as needed
  .
  
For patients already on another prophylactic regimen, their migraine is well controlled and current treatment can be continued as needed
.

• After 6 months of prophylactic treatment, the need for continued migraine prophylaxis should be assessed
  .
  
• After 6 months of prophylactic treatment, the need for continued migraine prophylaxis should be assessed
  .
  
After 6 months of prophylactic treatment, the need for continued migraine prophylaxis should be assessed
.

• For some migraine sufferers, riboflavin (400 mg once daily) is recommended to reduce the frequency and intensity of migraine
  .
  
• For some migraine sufferers, riboflavin (400 mg once daily) is recommended to reduce the frequency and intensity of migraine
  .
  
For some migraine sufferers, riboflavin (400 mg once daily) is recommended to reduce the frequency and intensity of migraine
.
3.
Migraine headaches in women and girls taking combined hormonal contraceptives 3.
Migraine headaches in women and girls taking combined hormonal contraceptives  
• Combined hormonal contraceptives should not be routinely offered for contraception in patients with migraine with aura .
  
  
• Combined hormonal contraceptives should not be routinely offered for contraception in patients with migraine with aura .
  
  
Combination hormonal contraceptives should not be routinely provided for contraception in patients with migraine with aura .
4.
Menstrual Migraine 4.
Menstrual Migraine
  
• For women with foreseeable menstrual-related migraines who do not respond to standard acute-phase treatments, Frovatriptan (2.
  5 mg twice a day) or zolmitril may be considered on the day of expected migraine attack Tan (2.
  5 mg each time, 2~3 times/day)
  .
  
• For women with foreseeable menstrual-related migraines who do not respond to standard acute-phase treatments, Frovatriptan (2.
  5 mg twice a day) or zolmitril may be considered on the day of expected migraine attack Tan (2.
  5 mg each time, 2~3 times/day)
  .
  
For women with foreseeable menstrual-related migraines who do not respond to standard acute-phase treatments, Frovatriptan (2.
5 mg twice a day) or zolmitril may be considered on the day of expected migraine attack Tan (2.
5 mg each time, 2~3 times/day)
.
5.
Pregnancy Migraine 5.
Pregnancy Migraine  
• Triptans or NSAIDs may be used after considering a woman's treatment needs and the risks associated with using each drug during pregnancy
  .
  Consultation with a specialist is recommended if preventive treatment of migraine is required during pregnancy
  .
  
• Triptans or NSAIDs may be used after considering a woman's treatment needs and the risks associated with using each drug during pregnancy
  .
  Consultation with a specialist is recommended if preventive treatment of migraine is required during pregnancy
  .
  
Triptans or NSAIDs may be used after considering a woman's treatment needs and the risks associated with using each drug during pregnancy
.
Consultation with a specialist is recommended if preventive treatment of migraine is required during pregnancy
.
6.
Cluster headache 6.
Cluster headache 【Acute treatment】   
• Oxygen, subcutaneous, or nasal triptan may be given
• Oxygen, subcutaneous, or nasal triptan may be given
Oxygen, subcutaneous, or nasal triptan may be given
• When oxygen is used for acute treatment: use 100% oxygen, wear a non-circulating mask and oxygen storage bag, and the oxygen flow rate is at least 12 liters/min; arrange to provide temporary and portable oxygen at home
  .
  
• When oxygen is used for acute treatment: use 100% oxygen, wear a non-circulating mask and oxygen storage bag, and the oxygen flow rate is at least 12 liters/min; arrange to provide temporary and portable oxygen at home
  .
  
When oxygen is used for acute treatment: use 100% oxygen, wear a non-circulating mask and oxygen storage bag, and the oxygen flow rate is at least 12 liters/min; arrange to provide temporary and portable oxygen at home
.

• When using triptans subcutaneously or nasally, ensure that adequate triptans are provided to the patient
  .
  This should be calculated based on the patient's number of previous cluster headache attacks, taking into account the maximum daily dose of the drug
  .
  
• When using triptans subcutaneously or nasally, ensure that adequate triptans are provided to the patient
  .
  This should be calculated based on the patient's number of previous cluster headache attacks, taking into account the maximum daily dose of the drug
  .
  
When using triptans subcutaneously or nasally, ensure that adequate triptans are provided to the patient
.
This should be calculated based on the patient's number of previous cluster headache attacks, taking into account the maximum daily dose of the drug
.

• Acetaminophen, NSAIDs, opioids, ergot, or oral triptans are not recommended .
  
  
• Acetaminophen, NSAIDs, opioids, ergot, or oral triptans are not recommended .
  
  
Acetaminophen, NSAIDs, opioids, ergot, or oral triptans are not recommended .
【Prophylactic treatment】
 
• When considering the use of verapamil as a prophylactic treatment for cluster headache, if you are unfamiliar with its use, you should seek expert advice, including ECG monitoring if necessary, before using verapamil
  .
  
• When considering the use of verapamil as a prophylactic treatment for cluster headache, if you are unfamiliar with its use, you should seek expert advice, including ECG monitoring if necessary, before using verapamil
  .
  
When considering the use of verapamil as a prophylactic treatment for cluster headache, if you are unfamiliar with its use, you should seek expert advice, including ECG monitoring if necessary, before using verapamil
.

• If verapamil does not respond to cluster headaches, seek expert advice
  .
  
• If verapamil does not respond to cluster headaches, seek expert advice
  .
  
If verapamil does not respond to cluster headaches, seek expert advice
.

• Expert advice should be sought if treatment of cluster headaches is required during pregnancy
  .
  
• Expert advice should be sought if treatment of cluster headaches is required during pregnancy
  .
  
Expert advice should be sought if treatment of cluster headaches is required during pregnancy
.
7.
Medication Overuse Headache 7.
Medication Overuse Headache  
• Explain to patients with headaches caused by overdose that the headache can be treated by discontinuing the overdose pain
  .
  
• Explain to patients with headaches caused by overdose that the headache can be treated by discontinuing the overdose pain
  .
  
Explain to people who have overdose on their headache
.

• Advise patients to stop taking medications that over-treat acute headaches for at least 1 month, and should be discontinued abruptly rather than gradually
  .
  
• Advise patients to stop taking medications that over-treat acute headaches for at least 1 month, and should be discontinued abruptly rather than gradually
  .
  
Advise patients to stop taking medications that over-treat acute headaches for at least 1 month, and should be discontinued abruptly, not gradually
.

• Patients should be reminded: Stop overuse of drugs, headache symptoms can be aggravated or even accompanied by stage symptoms in a short period of time before improving
  .
  Follow up closely and provide assistance according to the patient's needs
  .
  
• Patients should be reminded: Stop overuse of drugs, headache symptoms can be aggravated or even accompanied by stage symptoms in a short period of time before improving
  .
  Follow up closely and provide assistance according to the patient's needs
  .
  
Remind patients: Remind patients: Stop overuse of drugs, headache symptoms can be aggravated or even accompanied by stage symptoms in a short period of time before they improve
.
Follow up closely and provide assistance according to the patient's needs
.

• For underlying primary headaches, prophylactic treatment should be considered in addition to discontinuation of overused medications
  .
  
• For underlying primary headaches, prophylactic treatment should be considered in addition to discontinuation of overused medications
  .
  
For underlying primary headaches, prophylactic treatment should be considered in addition to discontinuation of overused medications
.

• Do not frequently offer inpatient discontinuation for headaches caused by overuse of medications
  .
  
• Do not frequently offer inpatient discontinuation for headaches caused by overuse of medications
  .
  
Do not frequently offer inpatient discontinuation for headaches caused by overuse of medications
.

• Specialist referral and/or hospitalized overdose discontinuation may be considered in patients who are using high-dose opioids, have associated complications, or have failed multiple prior attempts to discontinue overuse medication
  .
  
• Specialist referral and/or hospitalized overdose discontinuation may be considered in patients who are using high-dose opioids, have associated complications, or have failed multiple prior attempts to discontinue overuse medication
  .
  
Specialist referral and/or hospitalized overdose discontinuation may be considered in patients who are using high-dose opioids, have associated complications, or have failed multiple prior attempts to discontinue overuse medication
.

• Review the diagnosis of overdose headache and conduct further management 4 to 8 weeks after discontinuation of the overdose .
  
  
• Review the diagnosis of overdose headache and conduct further management 4 to 8 weeks after discontinuation of the overdose .
  
  
Review the diagnosis of overdose headache and conduct further management 4 to 8 weeks after the overdose is discontinued .
References: [1]Headaches in over 12s: diagnosis and management.
Clinical guideline Published: 19 September 2012 Last updated: 17 December 2021 https:// [2]Wang Cuidi.
Adolescents and Diagnosis and management of headache in adults: An outline of the NICE guidelines [J].
British Medical Journal Chinese Edition 2013, Vol.
16, No.
2, pp.
114-116, 2020 Leave a message here