NICE headaches

NICE on headache (   Guidance on assessment:
Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral.
  • worsening headache with fever
  • sudden-onset headache reaching maximum intensity within 5 minutes
  • new-onset neurological deficit
  • new-onset cognitive dysfunction
  • change in personality
  • impaired level of consciousness
  • recent (typically within the past 3 months) head trauma
  • headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
  • headache triggered by exercise
  • orthostatic headache (headache that changes with posture)
  • symptoms suggestive of giant cell arteritis
  • symptoms and signs of acute narrow-angle glaucoma
  • a substantial change in the characteristics of their headache.
Consider further investigations and/or referral for people who present with new-onset headache and any of the following:
  • compromised immunity, caused, for example, by HIV or immunosuppressive drugs
  • age under 20 years and a history of malignancy
  • a history of malignancy known to metastasise to the brain
  • vomiting without other obvious cause.
Consider using a headache diary to aid the diagnosis of primary headaches.  If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:
  • frequency, duration and severity of headaches
  • any associated symptoms
  • all prescribed and over the counter medications taken to relieve headaches
  • possible precipitants
  • relationship of headaches to menstruation.
This table is taken directly from and helps with the classification of the specific type of headache.
Headache feature Tension-type headache Migraine (with or without aura) Cluster headache
Pain location1 Bilateral Unilateral or bilateral Unilateral (around the eye, above the eye and along the side of the
Pain quality Pressing/tightening (non-pulsating) Pulsating (throbbing or banging in young people aged 12–17 years) Variable (can be sharp, boring, burning, throbbing or tightening)
Pain intensity Mild or moderate Moderate or severe Severe or very severe
Effect on activities Not aggravated by routine activities of daily living Aggravated by, or causes avoidance of, routine activities of daily living Restlessness or agitation
Other symptoms None Unusual sensitivity to light and/or sound or nausea and/or vomiting
Symptoms can occur with or without headache and:

  • are fully reversible
  • develop over at least 5 minutes
  • last 5−60 minutes.
Typical aura symptoms include visual symptoms such as flickering lights,
spots or lines and/or partial loss of vision; sensory symptoms such as
numbness and/or pins and needles; and/or speech disturbance.
On the same side as the headache:

  • red and/or watery eye
  • nasal congestion and/or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil and/or drooping eyelid
Duration of headache 30 minutes–continuous 4–72 hours in adults
1–72 hours in young people aged 12–17 years
15–180 minutes
Frequency of headache < 15 days per month ≥ 15 days per month for more than 3 months < 15 days per month ≥ 15 days per month for more than 3 months 1 every other day to 8 per day3, with remission4 >
1 month
1 every other day to 8 per day3,

with a continuous remission4 <1 month
in a
12-month period
Diagnosis Episodic

tension-type headache

Chronic tension-type headache5 Episodic migraine (with or without aura) Chronic migraine6 (with or without aura) Episodic cluster headache Chronic cluster headache
1 Headache pain can be felt in the head, face or neck.
2 See recommendations 1.2.2, 1.2.3 and 1.2.4 for further information on diagnosis of migraine with aura.
3 The frequency of recurrent headaches during a cluster headache bout.
4 The pain-free period between cluster headache bouts.
5 Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.
6 NICE has developed technology appraisal guidance on Botulinum toxin type A for the prevention of headaches in adults with chronic migraine
(headaches on at least 15 days per month of which at least 8 days are with migraine).

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