Diagnosis and management of 107 headache in adults A national clinical guideline November 2008 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias 2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+ GOOD PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development group. NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. This guideline has been assessed for its likely impact on the six equality groups defined by age, disability, gender, race, religion/belief, and sexual orientation. For the full equality and diversity impact assessment report please see the “published guidelines” section of the SIGN website at www.sign.ac.uk/guidelines/published/numlist.html. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk This document is produced from elemental chlorine-free material and is sourced from sustainable forests Scottish Intercollegiate Guidelines Network Diagnosis and management of headache in adults A national clinical guideline November 2008 DIAGNOSIS AND MANAGEMENT OF HEADACHE IN ADULTS ISBN 978 1 905813 39 1 Published November 2008 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Elliott House, 8 -10 Hillside Crescent Edinburgh EH7 5EA www.sign.ac.uk CONTENTS Contents 1 Introduction ................................................................................................................ 1 1.1 The need for a guideline .............................................................................................. 1 1.2 Remit of the guideline .................................................................................................. 1 1.3 Definitions ................................................................................................................... 2 1.4 Statement of intent ....................................................................................................... 2 2 Key recommendations ................................................................................................. 3 2.1 Symptoms and signs ..................................................................................................... 3 2.2 Assessment tools .......................................................................................................... 3 2.3 Investigations ............................................................................................................... 4 2.4 Migraine ...................................................................................................................... 4 2.5 Trigeminal autonomic cephalalgias .............................................................................. 4 2.6 Medication overuse headache ...................................................................................... 5 3 Symptoms and signs..................................................................................................... 6 3.1 Introduction ................................................................................................................. 6 3.2 Primary headache ........................................................................................................ 6 3.3 Secondary headache .................................................................................................... 9 4 Assessment tools .......................................................................................................... 13 5 Investigations............................................................................................................... 15 5.1 Neuroimaging .............................................................................................................. 15 5.2 Lumbar puncture in subarachnoid haemorrhage ........................................................... 17 5.3 Erythrocyte sedimentation rate, C-reactive protein and plasma viscosity in giant cell arteritis ............................................................................................................ 18 5.4 Other investigations ..................................................................................................... 18 6 Migraine ...................................................................................................................... 19 6.1 This section is superseded by SIGN 155: Pharmacological management of migraine 6.2 This section is superseded by SIGN 155: Pharmacological management of migraine 7 Tension-type headache ................................................................................................ 30 7.1 Acute treatment ............................................................................................................ 30 7.2 Pharmacological prophylaxis........................................................................................ 30 8 Trigeminal autonomic cephalalgias ............................................................................. 32 8.1 Acute treatment of cluster headache ............................................................................. 32 8.2 Pharmacological prophylaxis........................................................................................ 33 8.3 Treatment of paroxysmal hemicrania, hemicrania continua and SUNCT ..................... 34 9 Medication overuse headache ..................................................................................... 35 9.1 Definitions and assessment .......................................................................................... 35 9.2 This section is superseded by SIGN 155: Pharmacological management of migraine CONTROLDIAGNOSIS OF AND PAIN MANAGEMENT IN ADULTS WITH OF HEADACHE CANCER IN ADULTS 10 Pregnancy, contraception, menstruation and the menopause ..................................... 38 10.1 Pregnancy .................................................................................................................... 38 10.2 Oral contraception ....................................................................................................... 38 10.3 This section is superseded by SIGN 155: Pharmacological management of migraine 10.4 This section is superseded by SIGN 155: Pharmacological management of migraine. 11 Lifestyle factors ........................................................................................................... 41 11.1 Diet .............................................................................................................................. 41 11.2 Trigger avoidance......................................................................................................... 41 11.3 Exercise ........................................................................................................................ 41 11.4 Sleep ............................................................................................................................ 41 11.5 Stress management ....................................................................................................... 42 12 Psychological therapies ............................................................................................... 43 13 Physical therapies ........................................................................................................ 44 13.1 Manual therapy ...........................................................................................................