Guidelines for all doctors

in the diagnosis and management of

Migraine and Tension-Type Headache
2004

Writing Committee:
T.J. Steiner
E.A. MacGregor
P.T.G. Davies

Headache in the UK
Affects nearly everyone occasionally
Is a problem for around 40% of people
Is one of the most frequent causes of
consultation in both general practice and
neurological clinics
Represents an immense socioeconomic
burden

Migraine in the UK

Affects 12-15% of the population

Affects 3X more women than men
Most troublesome late teens to early 50s
Also occurs in children and the elderly

Migraine in the UK
An estimated 187,000 attacks every day
Almost 90,000 people absent from work or
school as a result
Annual cost through lost work and
impaired effectiveness may be 1.5 billion
Despite these statistics migraine seems to
be under-diagnosed and under-treated

Tension-type Headache (TTH)

Affects up to 80% of people
Often referred to as a normal or ordinary
headache by patients
Most do not consult a doctor
High prevalence results in a similar economic
burden to migraine via lost work or reduced working
effectiveness
2-3% of adults have chronic TTH (i.e. TTH >15 days
per month)
Chronic TTH can result in substantial disability and
work absence

British Association for the

Study of Headache (BASH)
Management Guidelines
Intended for all doctors who manage headache
- in general practice or specialist clinics
Provide management strategies supported by
specialists in the field
Should be incorporated by healthcare
commissioners into any agreement for provision
of service

British Association for the

Study of Headache (BASH)
Headache management requires a flexible
and individualized approach
BASH Guidelines can be tailored to
individual clinical circumstances

The International Headache

Society Classification
The International Headache Society (IHS)
classifies headache disorders under
primary and secondary conditions

IHS Classification
Primary Headaches
Migraine
Without aura
With Aura

Tension-type Headache
Episodic
Chronic

Cluster Headache and other trigeminal

autonomic cephalalgias

IHS Classification
Secondary Headaches
Headache attributed to

Head and/or neck trauma

Vascular disorders
Non-vascular intracranial disorders
A substance or its withdrawal
Infection
Disorder of homeostasis
Disorder of cranium neck, eyes, ears, nose, sinuses, teeth,
mouth or other facial or cranial structures
Psychiatric disorder

Cranial neuralgias and central causes of pain

Headache unspecified/not classified

Patient history
The key to diagnosis
History is all-important
No diagnostic tests for primary headache

Patient diaries can help identify patterns of

attacks and aid diagnosis*
Different headache types are not mutually
exclusive
Take a separate history for each headache type
In children, migraine and tension-type headache
may be less distinct than in adults
*Assuming a condition requiring urgent attention has already been ruled out

Headache history
Key questions
TIME
- Onset, frequency, patterns, duration?

CHARACTER
- Site, intensity, nature of pain?

CAUSES
- Predisposing, triggering, aggravating, relieving factors?
- Family history?

RESPONSE
- Patients actions and limitations during an attack?
- Medications used?

INTERVALS
- How does the patient feel between attacks?
- Concerns, anxieties and fears about attacks?

Migraine
Diagnostic Pointers
Typically
Recurrent episodic headaches with moderate or
severe pain
May be unilateral and/or throbbing
Last from 4 hours up to 3 days
Associated with gastrointestinal and visual
symptoms
Activity is limited and dark/quiet is preferred
Free from symptoms between attacks

IHS diagnostic criteria

Migraine without aura*
An idiopathic recurring headache with:
A. At least 5 attacks fulfilling B-D
B. Attacks last 4-72 hours
C. At least 2 of the following
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravated by routine physical activity
D. At least one of the following during an attack
- Nausea and/or vomiting
- Photophobia and phonophobia
E. Not attributed to another disorder
* In children, attacks may be shorter; also more commonly bilateral and GI
disturbance is more prominent

Diagnosis
Migraine with aura
Aura precedes headache
Symptoms of migraine aura:
Transient hemianopic disturbances prior to
headache, lasting 10-30 minutes (occasionally up
to 1 hour)
A spreading scintillating scotoma (patients may
draw a jagged crescent)
Other reversible focal neurological disturbances
e.g. unilateral paraesthesiae of hand, arm or face

Visual blurring and spots are not diagnostic

Patients may have attacks of migraine with aura
and migraine without aura at different times

Diagnosis by treatment
Can be tempting to use the specific antimigraine drugs as a diagnostic test
This approach is likely to mislead
Low sensitivity
Triptans are at best effective in only three
quarters of attacks

Low specificity
TTH in migraineurs can respond to triptans

Tension-type Headache (TTH)

TTH
Replaces tension headache and muscle
contraction headache
Typically generalized vice like or a tight
band
No nausea or photophobia

Tension-type Headache (TTH)

Occasional TTH is seldom disabling
(unlike chronic TTH)
Both TTH and migraine are aggravated by
stress (so can be hard to differentiate)
Headache more often than once a week
may be a mixture of TTH and migraine
Successful management is dependent on
recognition and management of each
separate headache type

Chronic Daily Headache

(CDH)
CDH
A descriptive, not diagnostic, term
Headache occurs on more days than not (>50% of the
time) over weeks or longer
Affects up to 4% of the population
Accounts for up to 40% of referrals to special
headache clinics
Costs the UK economy up to 1 billion per year in lost
working time yet is very poorly characterized

Headaches occurring every day are generally not

migraine (but may co-exist with migraine)
CDH includes chronic TTH & Chronic Migraine

Medication Overuse
Headache (MOH)
Affects an estimated 1 in 50 people
First noted with phenacetin and ergotamine
Typically results from overuse of OTC
analgesics
A related syndrome occurs with triptans
Accurate diagnosis is difficult in the
presence of MOH
A detailed medication history is essential

Cluster Headache (CH)

Formerly known as migrainous neuralgia
Generally affects men (ratio 6:1), often smokers,
in their 20s or older
Typically occurs in bouts for 6-12 weeks every
one or two years
Attacks typically occur at night, waking the
patient 1 to 2 hours after falling asleep, lasting
30 to 60 minutes
Pain is intense, probably as severe as renal
colic, and strictly unilateral

Physical examination of
headache patients

Physical examination can reassure patients

Optic fundi should always be examined
Blood pressure measurement is recommended
Examine head and neck for muscle tenderness,
especially in tension-type headache
Examine jaw and bite
Some paediatricians recommend head
circumference measurement for children, plotted
on a centile chart

Serious cause of headache 1

Intracranial tumours

Rarely produce headache until quite large

Epilepsy is a cardinal symptom
Loss of consciousness should be viewed very seriously
Focal neurological signs are generally present
Diagnosis harder in neurological silent areas of the frontal
lobes

Meningitis
Usually accompanied by fever and neck stiffness
Headache may be generalized or frontal (perhaps radiating
to the neck)
Nausea and disturbed consciousness may accompany
headache later

Serious cause of headache 2

Subarachnoid haemorrhage (SAH)

Usually, sudden onset of very severe explosive headache

Neck stiffness may take hours to develop
Classical signs and symptoms may be absent in the elderly
Sometimes confused with migraine thunderclap headache
Serious consequences of missing SAH call for a low
threshold of suspicion

Temporal arteritis (TA)

Suspect if new headache in patients over 50 years

Headache accompanied by marked scalp tenderness
Headache persistent but often worse at night
Jaw claudication is highly suggestive of TA

Serious cause of headache 3

Primary angle-closure glaucoma
Rare before middle age
Headache and eye pain can be dramatic or episodic and mild

Idiopathic intracranial hypertension

Formerly termed benign intracranial hypertension or
pseudotumor cerebri
Rare cause, usually in obese young women
History may suggest raised intracranial pressure
Papilloedema is diagnostic in adults
Diagnosis confirmed by CSF pressure measurement

Carbon monoxide (CO) poisoning

Headache is a symptom of sub-acute toxicity
Uncommon but potentially fatal

Migraine Management
Overview
Aim for effective control of symptoms
A cure is unrealistic

Under-treatment is not cost-effective

Results in unnecessary pain and disability
Repeat consultations are expensive

Migraine typically varies with time

Needs may change

Migraine Management
Overview
Four elements to effective migraine management
in adults
Correct and timely diagnosis
Explanation and reassurance
Identification and avoidance of predisposing/trigger factors
Drug or non-drug intervention

Children
Often respond to conservative migraine
management
If this fails, most can be managed as adults

Migraine
Predisposing Factors
Predisposing factors are different from
precipitating/trigger factors
Five main predisposing factors are
recognized
Stress
Depression/anxiety
Menstruation
Menopause
Head or neck trauma

Migraine
Trigger Factors
Trigger factors are seen in occasional patients
and include

Relaxation after stress: weekends/holidays

Change in habit: sleep, travel etc.
Bright lights/loud noise
Diet: alcohol, cheese, citrus fruits, possibly
chocolate (but evidence is inconclusive); missed
or delayed meals
Strenuous unaccustomed exercise
Menstruation

A trigger diary kept by patients can be useful

unless causes introspection

Migraine
Acute Drugs
Five step treatment ladder
Failure on three occasions is the minimum
criterion for moving to the next step

Migraine
Acute Drugs 1
Step 1: Oral analgesics Antiemetic
a) Simple analgesics, preferably soluble
Aspirin or paracetamol or ibuprofen
NOT codeine or dihydrocodeine

b) As above or prescription-only NSAID

plus prokinetic antiemetic
(metoclopramide or domperidone)
Contraindications:
Aspirin not recommended for children under 16
Metoclopramide not recommended for children or
adolescents

Migraine
Acute Drugs 2
Step 2: Parenteral Analgesic Antiemetic
Diclofenac suppositories
Plus
Domperidone suppositories
Contraindications:
Peptic ulcer or lower bowel disease
Diarrhoea
Patient non-acceptance

Migraine
Acute Drugs 3(i)
Step 3: Triptans
Marked inter-patient variation in response see which
suits the patient best
Ineffective if taken before onset of headache
Some experts suggest adding metoclopramide or
domperidone
Symptoms often relapse within 48 hours
Contraindications:
Uncontrolled hypertension
Risk factors for CHD or CVD
Children under 12 years

Migraine
Acute Drugs 3(ii)
Step 3: Ergotamine
Toxicity and misuse are potential drawbacks
Contraindications:
Ergotamine is not an option if triptans are
contraindicated and should not be taken
concomitantly with a triptan
Beta-blocker therapy
Not advised for children

Migraine
Acute Drugs 4
Step 4: Combinations
Steps 1+3 may be helpful, followed by Steps
2+3
Self-injected diclofenac may be tried

Migraine
Emergency Treatment
Emergency treatment at home
NOT pethidine
Intramuscular diclofenac
and/or

Intramuscular chlorpromazine
Antiemetic and sedative

Migraine
Repeated Relapse
Consider naratriptan, eletriptan or
frovatriptan
Ergotamine
Prolonged duration of action

Diclofenac or tolfenamic acid may be used

Pre-emptively if relapse is anticipated

Migraine
Prophylactic Drugs
Prophylactic therapy is used (in addition to acute
therapy) to reduce the number of attacks when
acute therapy alone gives inadequate symptom
control
Criteria for choice of prophylactic drug based on

Evidence of efficacy
Comorbidity and effect of drug
Contraindications, including risk of pregnancy
Frequency of dosing: once daily dosing is
preferable

Migraine
Prophylactic Drugs 1
First-line
Beta-blockers (atenolol,metoprolol,
propranolol, bisoprolol) if not contra-indicated
Amitriptyline when migraine co-exists with

TTH
Another chronic pain condition
Disturbed sleep
Depression

Migraine
Prophylactic Drugs 2
Second-line
Sodium valproate
Topiramate

Evidence for sodium valproate is

reasonable and clinical usage is extensive
Evidence for topiramate is very good but
clinical usage is as yet limited

Migraine
Prophylactic Drugs 3
Third-line
Gabapentin
Methysergide
Beta-blockers and amitriptyline (in
combination)

Migraine
Prophylactic drugs 4
Other options (limited efficacy)
Pizotifen
Verapamil
SSRIs

Migraine
Menstrual attacks
Perimenstrual prophylaxis
Non-hormonal
Mefenamic acid - first-line in migraine occurring with
menorrhagia and/or dysmenorrhoea

Oestrogen
If the women has an intact uterus and is menstruating
regularly, no progestogens are necessary

Combined oral contraceptives

Migraine without aura in pill-free interval may resolve with a
more oestrogen-dominant pill
Not recommended for women with migraine with aura

Migraine
HRT
Migraine and hormone replacement therapy
The menopause itself commonly exacerbates
migraine
Symptoms can be relieved with HRT
No evidence that risk of stroke is elevated or
reduced by use of HRT in women with migraine
Some women on HRT find migraine worsens
Often solved by reducing dose and/or changing to
non-oral formulation

Migraine
Non-drug Intervention

Improving physical fitness

Physiotherapy (but no evidence)
Acupuncture
Psychological therapy
Relaxation
Stress reduction
Coping strategies
Biofeedback

Tension-type Headache (TTH)

Management
Infrequent episodic TTH (<2 days/week)
Reassurance
Symptomatic treatment
Aspirin, paracetamol or ibuprofen
Codeine and dihydrocodeine should be
avoided

Tension-type Headache (TTH)

Management
Chronic TTH
Symptomatic treatment may give shortterm relief but is inappropriate long-term
Consider a course of naproxen
May break the cycle
May stop overuse of analgesics

Amitriptyline is the prophylactic of choice

Tension-type Headache (TTH)

Management
Non-drug interventions
Regular exercise
Physiotherapy
Stress-coping strategies
Acupuncture

Co-existing Headaches
Management
Restrict symptomatic medication
Max 2 days per week

Prophylaxis for migraine coexisting with

episodic TTH
Amitriptyline
Sodium valproate

BASH Guidelines
Effects of Implementation
Improve diagnosis
Increase the number of
patient with migraine
using triptans
Reduce misuse of
medication, including
triptans
Reduce the need for
specialist referral

Improve the overall

effectiveness of
headache management
Reduce inappropriate
treatment
Improved treatment for
each patient
Improve outcome
Reduce iatrogenic
illness
Reduce disability

BASH Guidelines
Effects of Implementation
Initially increases the no. of consultations per
patient
BUT
Reduces the overall number of consultations
Raises expectations, especially amongst those
with migraine, leading to more patients
consulting
BUT
Reduces the overall burden of illness, with savings
elsewhere

Audit
Judging Effectiveness
Aims of Audit
To measure direct treatment costs
Consultations, referrals and prescriptions

To measure headache burden

Before and after implementation of BASH guidelines

Migraine Disability Assessment (MIDAS) may be

useful in the audit process
A self-administered questionnaire
Measures the adverse effect of headache on work
and social activities over the preceding 3 months