Executive summary
- Diagnosis: Migraine (unilateral, pulsating, nausea, photophobia) vs Tension (bilateral, pressing, "tight band") vs Cluster (severe unilateral eye pain + autonomic signs).
- The Trap: Medication Overuse Headache. Suspect if taking triptans/opioids/NSAIDs ≥10-15 days/month. Treatment is abrupt withdrawal (it gets worse before it gets better).
- Neuroimaging: Do NOT refer for scan solely for reassurance if pattern is typical migraine/tension.
Migraine Management
- Acute Treatment (The "Rescue"):
- Combination: Triptan + NSAID (or Paracetamol).
- Sumatriptan: 50mg-100mg oral (at onset). May repeat after 2h (max 300mg/24h). Do not use for prophylaxis.
- Zolmitriptan/Rizatriptan: Alternatives if Sumatriptan fails/poorly tolerated.
- Prophylaxis (The "Preventer"):
- Offer if: Impact on QoL, or ≥2 attacks/month.
- 1. Topiramate: 25mg nocte -> Titrate to 50mg bd. Highly Teratogenic. (Must be on highly effective contraception).
- 2. Propranolol: 80mg Slow Release od -> Titrate to 160mg. (Avoid in asthma).
- 3. Amitriptyline: 10mg nocte -> Titrate to 25-50mg. (Good if sleep disturbed).
- Review: Trial for 6 months minimum.
- Red Flags (Refer Urgent):
- Thunderclap (sudden onset, max intensity <5 mins).
- New headache >50 years.
- Worse on coughing/straining/posture change (raised pressure).
- Focal neurology/Confusion.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.