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Headache History

For the patient presenting with headache for the first time or with a significant change in headache pattern, the headache history should include information on the following:

1. Headache onset (thunderclap, association with head or neck trauma), previous attacks (progression of symptoms), duration of attacks (under 3 hours, over 4 hours, continuous), and days per month or week with headache
2. Pain location (unilateral, bilateral, frontal, periorbital, occipital; associated neck pain)
3. Headache associated symptoms (nausea, vomiting, photophobia, phonophobia, conjunctival injection, or rhinorrhea)
4. Relationship of headache to possible precipitating factors (stress, posture, cough, exertion, straining, neck movement, jaw pain, etc.)
5. Headache severity and effect of the headaches on work and family activities
6. Acute and preventive medications tried in the past, and response to these medications and side effects
7. Presence of co-existent conditions that may influence treatment choice (insomnia, depression, anxiety, hypertension, asthma, and history of heart disease or stroke)

Refer to Appendix B: Headache History Guide in the original guideline document.

Physical Examination

Patients presenting to a healthcare provider for the first time with headache, or with a headache that differs from their usual headache, should have a physical examination that includes the following: 1) a screening neurological examination; 2) a neck examination; 3) a blood pressure measurement; 4) a focused neurological examination, if indicated; and 5) an examination for temporomandibular disorders, if indicated.

Screening Neurological Examination

The screening neurological examination should consist of the following:

1. General assessment of mental status
2. Cranial nerve examination: fundoscopy, examination of pupils for symmetry and reaction to light, eye movements, visual field examination, and evaluation of facial movement for asymmetry and weakness
3. Assessment of all four limbs for unilateral weakness, reflex asymmetry, and evaluation of coordination in the upper limbs
4. Assessment of gait, including heel-toe walking (tandem gait)

Neck Examination

Physical examination of patients with headache should include an assessment of neck posture and range of motion, and palpation for muscle tender points.

Focused Neurological Examination

A focused neurological examination should be added if indicated by patient symptoms and/or abnormal signs on the screening examination (e.g., dysarthria would lead to more detailed assessment of lower cranial nerves; reflex asymmetry would lead to assessment of plantar responses).

Examination for Temporomandibular Disorders

In the patient with headache and associated jaw complaints, the physical examination should include clinical assessment of jaw movements and palpation of the muscles of mastication for tender points.

Patients with recurrent headache attacks and a normal neurological examination (other clinical symptoms may need to be considered as well, in some patients):

1. Diagnose migraine without aura (migraine with aura if an aura is present) if they have at least two of: 1) nausea during the attack, 2) light sensitivity during the attack; 3) some of the attacks interfere with their activities. Refer to "Management of Migraine Headache," below.

2. Diagnose episodic tension-type headache if headache attacks are not associated with nausea, and have at least two of the following: 1) bilateral headache; 2) non-pulsating pain; 3) mild to moderate intensity; and 4) headache is not worsened by activity. Refer to "Management of Tension-Type Headache," below.

3. Diagnose cluster headache or another trigeminal autonomic cephalalgia if headache attacks fit all the following: 1) frequent; 2) severe; 3) brief (duration of less than 3 hours); 4) unilateral; and 5) ipsilateral conjunctival injection and/or tearing and/or restlessness during the attacks (ipsilateral ptosis and/or miosis may be present on examination). Refer to "Management of Cluster Headache," below; neurologist referral recommended.

Patients with headache on 15 or more days per month for more than 3 months and with a normal neurological examination:

1. Diagnose chronic migraine if their headaches meet migraine diagnostic criteria (above) or are quickly aborted by migraine specific medications (triptans or ergots) on 8 days a month or more.

1. Chronic migraine with medication overuse if the patient uses ergots, triptans, opioids, or combination analgesics on 10 days a month or more; or uses plain acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) on 15 days a month or more. Refer to "Management of Medication Overuse Headache," below.

2. Chronic migraine without medication overuse if patients do not have medication overuse as defined above. Refer to "Management of Migraine Headache," below.

2. Diagnose chronic tension-type headache if their headaches meet episodic tension-type headache diagnostic criteria (above), except mild nausea may be present. Refer to "Management of Tension-type Headache," below.

Although chronic migraine and chronic tension-type headache may result in continuous headache in some patients, two other less common headache syndromes should be considered in patients with continuous headache. Patients with continuous daily headache for more than 3 months with a normal neurological examination:

1. Diagnose hemicrania continua if the headache: 1) is strictly unilateral; 2) is always on the same side of the head (ptosis and/or miosis may be present on examination); and 3) responds dramatically to indomethacin. Refer to "Other Headache Disorders," below (neurologist referral recommended).

2. Diagnose new daily persistent headache if the headache is unremitting since its onset. It is important to consider secondary headaches in these patients. Neurologist referral recommended.

Cervicogenic headache should be considered in patients with neck pain and occipital head pain, with or without pain radiation to other head regions (or face), when pain is precipitated or aggravated by neck movements or sustained neck postures and there are abnormalities on examination of the neck (abnormal movement, muscle tone, or muscle tenderness). If the headache occurs after neck trauma and persists for more than 3 months, the term "chronic headache attributed to whiplash injury" should be used.

Caution: Patients with migraine often complain of neck discomfort during a headache and may have muscular tender points. These appear to be secondary to the migraine pain, and do not necessarily indicate a neck disorder as cause of the headache.

Post-traumatic headache should be diagnosed when a new headache disorder begins within 7 days of a head injury. These may occur even after a mild head injury. If the headache persists for more than 3 months, it is termed a chronic post-traumatic headache.

Temporomandibular disorder should be considered in patients with headache and/or facial pain who have painful jaw clicking, jaw locking, tenderness of muscles of mastication, tenderness of the temporomandibular joints, or limitation of mandibular movement.

Emergency Red Flags: (need to be addressed immediately)

1. Thunderclap headache: Onset of severe headache that is sudden (seconds to 1 minute from onset to peak intensity).

Patients presenting with severe headache of sudden onset (thunderclap headache) should be sent to an emergency department with urgent computerized tomography (CT) capability for immediate investigation to exclude subarachnoid hemorrhage. If subarachnoid hemorrhage is not present on head CT scanning, other investigations (e.g., lumbar puncture) may be necessary. Specialist involvement and further neuroimaging may also be necessary, as the differential diagnosis for thunderclap headache includes arterial dissection, dural sinus thrombosis, pituitary apoplexy, and reversible cerebral vasoconstriction syndrome.

2. Headache with fever and neck stiffness (meningismus): Patients with suspected bacterial meningitis should be sent immediately to an emergency department with urgent CT and lumbar puncture capability for investigation and treatment. Antibiotic therapy should not be unduly delayed by these investigations.

3. Papilloedema in a patient with altered level of consciousness and/or focal signs: Patients with papilloedema and altered level of consciousness and/or focal neurological signs may have a space-occupying lesion and may be at risk for incipient transtentorial herniation. They should be sent immediately to an emergency department with neuroimaging capability and specialist resources for investigation and treatment.

4. Acute angle-closure glaucoma: Patients with head pain and signs and symptoms of acute angle-closure glaucoma (non-reactive mid-dilated pupil, acutely inflamed eye, and visual disturbance with pain and nausea) should be sent immediately for assessment by an ophthalmologist or to an emergency department with the capability to measure intraocular pressure and initiate treatment.

Urgent Red Flags (need investigation and referral within hours to days)

1. Signs of systemic illness in the patient with new onset headache: Patients with new onset headache or a major change in headache pattern and a systemic illness (cancer, human immunodeficiency virus [HIV], etc.) that may indicate a serious cause for the headache may require urgent specialist consultation and/or investigation.

2. New headache in patients over 50 years of age with other symptoms suggestive of temporal arteritis: Patients over 50 years of age with new onset headache and other symptoms of temporal arteritis (jaw claudication, transient visual loss, etc.) should receive urgent investigation (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], and if indicated, temporal artery biopsy), and may require specialist consultation and early systemic corticosteroid treatment.

3. Papilloedema in an alert patient without focal neurological signs: Patients with papilloedema, a normal level of consciousness, and no focal neurological signs may have benign intracranial hypertension (pseudotumour cerebri). They should have urgent specialist referral and will need urgent neuroimaging. An intracranial space-occupying lesion should be ruled out prior to lumbar puncture to measure cerebrospinal fluid (CSF) pressure. Further investigation may be required as the differential diagnosis would include cerebral venous sinus thrombosis.

4. Elderly patient with new headache and subacute cognitive change: Elderly patients with a new headache and a recent subacute (days to weeks) decline in cognition may have a subacute or chronic subdural hematoma. A history of head injury is not always present. They require urgent specialist referral and/or brain CT imaging.

Imaging in Typical Migraine

As the diagnostic yield of neuroimaging in patients with typical recurrent migraine attacks is very low, neuroimaging is not indicated in patients with recurrent headaches with the clinical features of migraine, a normal neurological examination, and no red flags for potential causes of secondary headache.

Sinus x-rays and cervical spine x-rays are not recommended for the routine evaluation of the patient with migraine.

Atypical Headaches and Changes in Headache Pattern

Patients with headaches that do not fit the typical pattern of migraine or tension-type headache, and patients with a major change in headache pattern should be considered for specialist consultation and/or neuroimaging, depending on the clinical judgement of the practitioner. A non-contrast brain CT scan is usually sufficient to rule out a space-occupying lesion as a cause of headache.

Unexplained Focal Signs in the Patient with Headache

Patients with unexplained focal neurological signs and recurrent headache require specialist referral and/or neuroimaging to exclude a space-occupying central nervous system (CNS) lesion.

In the non-urgent setting, brain magnetic resonance imaging (MRI) is the neuroimaging procedure of choice, but a non-contrast brain CT is usually adequate to exclude a space-occupying lesion as a cause of headache.

Unusual Headache Precipitants

Patients with headache clearly precipitated by exertion, cough, or valsalva should be considered for specialist referral and/or a brain MRI scan to exclude a Chiari 1 malformation or a posterior fossa lesion (but it must also be considered that patients with typical migraine may have exertion as one of their headache triggers).

Patients in whom postural change has a major effect on headache intensity need specialist consultation and will require investigation.

For headache that worsens on standing, brain MRI scanning with gadolinium enhancement may be needed to look for indirect evidence of a CSF leak (dural enhancement, etc.).

For headache that worsens on lying down, a brain CT or MRI scan can be used to exclude a space-occupying lesion. As the differential diagnosis includes cerebral venous sinus thrombosis, additional investigation may be required.

Unusual Aura Symptoms

For patients with unusual aura symptoms, consider referral to a neurologist for diagnosis and possible investigation.

Cluster Headache and Other Uncommon Primary Headache Syndromes

In patients with new onset cluster headache or another trigeminal autonomic cephalalgia, hemicrania continua, or new daily persistent headache, specialist referral should be considered for treatment and investigation.

Late Onset Headache

For patients with headache that begins after the age of 50 years and who have no other red flags, consider non-contrast brain CT scan for space-occupying lesion and/or complete blood count (CBC), ESR, and CRP to investigate for giant cell (temporal) arteritis.

Neuroimaging for Patient Reassurance

Clinicians considering neuroimaging primarily for patient reassurance in patients with headache should consider whether this is in the best interest of the patient, and a prudent use of resources, or whether other means of reassurance (i.e., careful explanation of the circumstances, patient education, or specialist referral) would be more advisable. Clinicians requesting neuroimaging should be aware that any imaging study, particularly MRI, can identify incidental findings which may or may not correlate with clinical findings, and which may cause unnecessary patient anxiety.

Electroencephalography (EEG)

An EEG is not recommended for the routine evaluation of patients with headache.

Headache Diaries

Consider encouraging patients to keep a headache diary to monitor headache frequency, intensity, triggering factors, and medication use. Refer to patient handout, Headache Diary Sheet .

Additional Assessment of Disability

The degree of migraine-related disability present should be assessed clinically. Practitioners may find formal disability scales helpful in selected patients. Headache Impact Test (HIT-6) , and the Migraine Disability Assessment Scale (MIDAS) .

Psychiatric Comorbidities

Assessment of patients with migraine should include a clinical evaluation for the presence of significant depression and/or anxiety. If present, these should be treated according to evidence-based mental health recommendations.

Lifestyle Factors

Patients should be advised to adjust their lifestyle to avoid exacerbating their migraine (e.g., avoid missing meals; avoid dehydration; maintain adequate, regular sleep).

A general exercise program should be considered part of comprehensive migraine management.

Specific Migraine Triggers

Patients should be advised to consider whether some of the commonly reported migraine triggers, including food triggers, are important for them. A headache diary is helpful in this assessment. Refer to patient handouts: Headache Diary Sheet  and Commonly Reported Food Triggers for Migraine Attacks .

Assessment of the Need to Change a Patient's Acute Migraine Medication

Patients should be specifically assessed at follow-up visits to determine if their acute migraine medications need to be changed.

Early Treatment of Migraine Attacks

Advise patients to take their medication early in their migraine attack, where possible, to improve effectiveness. The strategy may not be appropriate for patients with frequent attacks who are at risk for medication overuse headache (see medication overuse recommendation). For patients with migraine with aura, it is usually advisable to take acute medication just as the headache phase is starting, rather than during the aura, although taking oral medication during the aura appears effective for many patients.

Rescue Medication

For severe migraine attacks, consider providing an additional rescue medication if the patient's usual acute medication does not work consistently for every attack.

NSAIDs and Acetaminophen

Acetylsalicylic acid 1000 mg, ibuprofen 400 mg, and naproxen sodium 500 to 550 mg are recommended for acute treatment in patients with migraine of all severities.

Acetaminophen 1000 mg is recommended for acute treatment of migraine attacks of mild to moderate severity. Daily dosage should not exceed 4 grams per day to avoid liver dysfunction.

If NSAIDs and/or acetaminophen are not effective by history or after a brief treatment trial, alternative medications (e.g., a triptan) should be tried.

NSAIDs can cause gastric irritation and bleeding and renal dysfunction.

Triptans

Oral triptans are recommended for acute treatment for all severities of migraine if previous attacks have not been controlled by simple analgesics. If a patient does not respond well to one triptan, a different triptan should be offered.

Patients with recurrence of their migraine attack after initial relief from a triptan should be advised to take a second dose (within recommended dosage limits), as this is usually an effective strategy.

Nasal zolmitriptan 5 mg and nasal sumatriptan 20 mg are recommended for acute treatment for all severities of migraine if previous attacks have not been controlled by simple analgesics. They may be helpful in patients with nausea and where oral triptans have been ineffective.

Subcutaneous sumatriptan 6 mg should be considered for patients with severe migraine, including those in whom other triptan formulations have been ineffective. It can be particularly helpful where vomiting precludes effective use of the oral route.

Triptans are vasoconstrictors and should be avoided in patients with cardiovascular disease.

Triptan and NSAID Combinations

In patients with an inadequate response to triptans alone, a combination of sumatriptan 50 mg to 100 mg and naproxen sodium 500 to 550 mg may be more effective. This approach may be particularly helpful for patients with prolonged attacks and/or headache recurrence. Although demonstrated only for the sumatriptan-naproxen combination, it might be expected that combinations of naproxen sodium 500 to 550 mg (or other NSAIDs) with other triptans in the usual doses would also be helpful.

Antiemetics

Metoclopramide (10 mg up to 4 times per day orally) and domperidone (10 mg up to 3 times per day) are recommended to treat nausea and potential emesis in migraine. These drugs may improve the absorption of analgesics.

Domperidone has fewer side effects than metoclopramide.

Intravenous metoclopramide (10 mg) can be used in the acute treatment of patients with migraine.

Side effects include akathisia and dystonia.

Dihydroergotamine (DHE)

DHE by nasal spray or subcutaneous/intramuscular injection may be considered for patients who do not respond well to triptans.

Ergotamine

Ergotamine is not recommended for routine use in patients with acute migraine, although it may be helpful for selected patients where triptans are not an option.

Because it is a vasoconstrictor, it should not be used in patients with cerebrovascular or cardiovascular disease.

Opioids

Opioid analgesics and combination analgesics containing opioids (e.g., codeine) are not recommended for routine use for the treatment of migraine owing to their potential for causing medication overuse headache.

Opioids may be necessary when other medications are contraindicated or ineffective, or as a rescue medication when the patient's usual medication has failed.

For more information on the use of opioids for chronic non-cancer pain, consult the National Guideline Clearinghouse summary of the National Opioid Use Guideline Group's Canadian guideline for safe and effective use of opioids for chronic non-cancer pain (guideline endorsed by the College of Physicians and Surgeons of Alberta).

Butalbital

The use of butalbital-containing combination analgesics in migraine management should be avoided and limited to exceptional circumstances where other acute medications are contraindicated and/or ineffective. When used, they should be carefully monitored to avoid medication overuse (use on less than 10 days per month) and dependence.

Indications for Migraine Preventive Medication

Consider migraine pharmacological prophylactic therapy in the following situations:

1. Recurrent migraine attacks are causing significant disability despite optimal acute drug therapy.
2. The frequency of acute medication use is approaching levels that place the patient at risk for medication overuse headache:Recurrent attacks with prolonged aura are occurring (hemiplegic migraine, basilar-type migraine, etc.).
   • Use of acute medication on 10 days a month or more for triptans, ergotamines, opioids, and combination analgesics
   • Use of acute medications on 15 days a month or more for acetaminophen and NSAIDs
4. Contraindications to acute migraine medications are making symptomatic treatment of individual migraine attacks.

Choosing a Specific Migraine Preventive Medication

A preventive medication should be chosen based on the following:

1. Evidence for efficacy
2. Side effect profile and contraindications
3. Co-existent medical and psychiatric disorders:
   • The number of medications required can be minimized by using migraine preventive drugs which can also treat other disorders that may co-exist with migraine (e.g., anxiety, depression, hypertension, insomnia).
   • Some migraine preventive drugs are contraindicated by co-existent disorders (e.g., flunarizine in depression).

Prescribing a Migraine Preventive Medication

1. Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage.
2. Ensure that patients have realistic expectations as to what the likely benefits of pharmacological prophylaxis will be. That is:Evaluate the effectiveness of therapy through the use of patient diaries that record headache frequency, drug use, and disability levels.
   • Headache attacks will likely not be abolished completely.
   • A reduction in headache frequency of 50% is usually considered worthwhile and successful.
   • It may take 4 to 8 weeks for significant benefit to occur.
   • If the prophylactic drug provides significant benefit in the first 2 months of therapy, this may increase further over several additional months of therapy.
4. For most prophylactic drugs, initiate therapy with a low dose and increase the dosage gradually to minimize side effects.
5. Increase the dose until the drug proves effective, until dose-limiting side effects occur, or a target dose is reached.
6. Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6 to 8 weeks after dose titration is completed.
7. Because migraine attack tendency fluctuates over time, gradual discontinuation of the drug should be considered for many patients after 6 to 12 months of successful prophylactic therapy, but preventive medications can be continued for much longer in patients who have experienced significant migraine-related disability.

Beta-Blockers

The following beta-blockers are recommended for migraine prophylaxis:

• Propranolol 80 mg to 240 mg daily

• Nadolol 80 mg to 160 mg daily

• Metoprolol 100 mg to 200 mg daily

Beta-blockers may be helpful in patients with comorbid anxiety.

Side effects of beta-blockers include fatigue and hypotension. They should be avoided or used with caution in patients with asthma, diabetes, bradycardia, and peripheral vascular disease.

Antidepressants

Amitriptyline is recommended for migraine prophylaxis:

• Dosage range 10 mg to 100 mg daily.

• To assist with tolerability, it should be started at a low dose (10 mg daily is recommended) with the dose being built up slowly (10 mg per week is recommended). The total daily dose is usually given at bedtime or an hour or two before bedtime.

• May be preferred in patients with migraine and depression, tension-type headache, insomnia, or anxiety.
• It is contraindicated in patients with angle-closure glaucoma.

Common side effects are dry mouth and sedation.

Venlafaxine 75 mg to 150 mg daily is an alternative to amitriptyline for migraine prophylaxis, although evidence for its efficacy is limited.

Nortriptyline can be considered for migraine prophylaxis. The dosage is similar to that of amitriptyline.

Selective serotonin reuptake inhibitors are not recommended in the prophylaxis of migraine.

Antiepileptics

Topiramate 50 mg to 200 mg daily (usual target dose 100 mg daily) is recommended for migraine prophylaxis.

• May be preferred in patients with obesity.

• Should be started at a low daily dosage (25 mg), and the daily dosage should be increased slowly (25 mg each week or every two weeks).

• Can result in a number of side effects including paresthesias, cognitive problems, word finding difficulty, and weight loss.
• Should be avoided in pregnant patients or those with angle-closure glaucoma.
• Should be avoided or used with caution in patients with a history of renal calculi.

Divalproex sodium 750 mg to 1500 mg daily is recommended for migraine prophylaxis.

• May be preferred in patients with comorbid depression.

• Should be avoided in women who are pregnant or of child bearing potential and patients with liver disease.

• Can result in a number of side effects including hair loss, tremor, and weight gain.
• Is associated with serious fetal malformations (neural tube defects).

Gabapentin (900 to 2400 mg daily) is recommended for migraine prophylaxis.

Vitamins, Minerals and Herbals

The following vitamins, minerals, and herbal compounds are recommended for migraine prophylaxis. They may have lower efficacy than drug prophylactics (expert opinion), but all have minimal side effects:

• Butterbur (Petasites hybridus) 75 mg twice a day

• Riboflavin 400 mg daily

• Magnesium citrate 300 mg twice a day

• Co-enzyme Q10 100 mg three times a day

Feverfew is not recommended for migraine prophylaxis.

Other Medications

Candesartan 8 mg daily for one week, then 16 mg daily is recommended for migraine prophylaxis. It has few side effects, but experience with this drug in migraine prophylaxis is limited.

Pizotifen 1.5 mg to 4 mg daily is recommended for migraine prophylaxis.

Side effects are common and include somnolence and weight gain.

Flunarizine 10 mg at bedtime is recommended for migraine prophylaxis. It should not be used in patients with a history of depression.

Side effects are common and include weight gain and depression.

OnabotulinumtoxinA (botulinum toxin A) 155 to 195 Units injected as per protocol every 3 months by clinicians experienced in its use for headache is recommended for prophylaxis of chronic migraine only (migraine with headache on more than 14 days a month).

NSAIDs are not recommended for migraine prophylaxis.

There is insufficient evidence to recommend for or against the use of verapamil for migraine prophylaxis.

Relaxation Training, Biofeedback, and Cognitive Behavioural Therapy (CBT)

Psychological therapies, including relaxation training, biofeedback, and CBT (alone or in combination), are treatment options for motivated patients with migraine. These therapies are considered to be effective components of stress management training.

Specific recommendations regarding which of these therapies to use for specific patients cannot be made.

Acupuncture

Acupuncture can be considered in the prophylactic treatment of patients with migraine. Treatment should consist of at least one to two sessions per week for several (2 or more) months, with each treatment lasting approximately 30 minutes.

Homeopathy

Homeopathy is not recommended for migraine prophylaxis.

Hyperbaric Oxygen

There is insufficient evidence to recommend for or against hyperbaric oxygen for acute treatment of migraine attacks and migraine prophylaxis. Lack of availability and cost would make this therapy impractical for routine use.

Normobaric Oxygen

There is insufficient evidence to recommend for or against the use of 100% normobaric oxygen for acute migraine treatment.

There is insufficient evidence to make a recommendation for or against the use of the following interventions for migraine management:

• Acrylic splints

• Hypnotherapy

• Massage

• Spinal manipulation

• Transcutaneous electrical nerve stimulation (TENS)

Acute Medications

The acute treatment of menstrual migraine attacks is similar to the acute treatment of non-menstrual migraine attacks. If patients do not respond to simple analgesics (acetaminophen, NSAIDs), a triptan should be used.

Prophylactic Treatment

For patients with refractory menstrual migraine headache, frovatriptan 2.5 mg twice a day can be considered, with frovatriptan administration starting 2 days before the anticipated onset of the menstrually associated migraine attack and continuing for a total of 6 days.

Drugs for migraine should be avoided during pregnancy where possible.

Ergot alkaloids should not be used during pregnancy.

When necessary, acetaminophen 1000 mg and metoclopramide 10 mg can be used for the treatment of migraine in pregnancy. As with any medication used during pregnancy, acetaminophen should be taken at the lowest effective dose for the shortest time necessary. The total daily dose should not exceed 4 grams.

Where analgesia beyond acetaminophen is needed, acetaminophen - codeine combination analgesics can be used in pregnancy.

Ibuprofen 400 mg can be used for acute migraine attacks during the second trimester of pregnancy. All NSAIDs, including ibuprofen, should be avoided in the third trimester of pregnancy.

The risks associated with the use of sumatriptan during pregnancy appear to be minimal, but there is insufficient evidence to make a recommendation for or against the use of sumatriptan in pregnancy. Sumatriptan should not be used routinely in pregnancy, but may be considered for use when other medications have failed and the benefits outweigh the risks. There is much less information or experience available regarding the safety of the other triptans during pregnancy.

Preventive drugs for migraine should be avoided during pregnancy where possible.

Preventive drugs for migraine should be gradually discontinued prior to the commencement of a planned pregnancy or should be stopped as soon as possible during an unplanned pregnancy.

When it is necessary to continue migraine prophylaxis during pregnancy, obtaining specialist advice should be considered.

The following drugs are recommended for the acute treatment of TTH (use on 15 days a month or more should be avoided):

• Ibuprofen (200 mg to 400 mg)
• Acetylsalicylic acid (500 mg to 1000 mg)
• Naproxen (275 mg to 500 or 550 mg)

  NSAIDs: gastrointestinal side effects, including bleeding

• Acetaminophen (500 mg to 1000 mg oral)

  Less risk of gastrointestinal side effects compared to NSAIDs

Combination analgesics containing caffeine are drugs of second choice. Combining caffeine with ibuprofen and acetaminophen increases efficacy, but possibly also the risk for developing medication overuse headache.

The following drugs are not recommended for routine use in acute treatment of TTH:

• Muscle relaxants

• Opioids, including combination analgesics containing codeine

• Triptans

• Amitriptyline (10 mg to 100 mg daily)

  Side effects include dry mouth, drowsiness, dizziness, constipation, and weight gain.

Drugs of second choice:

• Mirtazapine (30 mg daily)

  Side effects include drowsiness and weight gain.

• Venlafaxine (150 mg daily)

  Side effects include vomiting, nausea, dizziness, and loss of libido.

OnabotulinumtoxinA (botulinum toxin A) is not recommended for prophylaxis of chronic TTH.

Cognitive Behavioural Therapy (CBT), Biofeedback, and Relaxation Training

CBT, biofeedback, and relaxation training may be considered for patients with frequent TTH.

Exercise

A therapeutic exercise program, based on an assessment by an appropriately trained health professional, may be considered for patients with TTH.

Physical Therapy and Acupuncture

Physical therapy and acupuncture may be considered for patients with frequent TTH.

There is insufficient evidence to make a recommendation for or against the use of the following interventions for the treatment of patients with TTH:

• Hypnotherapy

• Massage

• TENS

Drugs for TTH should be avoided during pregnancy where possible.

Acetaminophen in a dose of 500 mg to 1000 mg is the treatment of choice in pregnant patients with TTH when headache pain is sufficient to require analgesia. As with any medication used during pregnancy, acetaminophen should be taken at the lowest effective dose for the shortest time necessary. The total daily dose should not exceed 4 grams.

If acetaminophen provides insufficient analgesia, ibuprofen 400 mg can be used in the second trimester of pregnancy. All NSAIDs, including ibuprofen, should be avoided in the third trimester of pregnancy.

Preventive drugs for TTH should be avoided during pregnancy where possible.

Preventive drugs for TTH should be gradually discontinued prior to the commencement of a planned pregnancy or should be stopped as soon as possible during an unplanned pregnancy.

Prophylactic treatment for TTH would only rarely be considered necessary in pregnancy. When necessary, obtaining specialist advice should be considered.

Consider a diagnosis of medication overuse headache in patients with headache on 15 days a month or more, and assess the patient for possible medication overuse.

When medication overuse headache is suspected, the patient should also be evaluated for the presence of the following:

• Psychiatric comorbidities (depression and anxiety); these may need to be considered in planning an overall treatment strategy.
• Psychological and physical drug dependence

• Use of inappropriate coping strategies: Medication overuse behaviour may occur in some patients because they have a limited repertoire of other more adaptive and pro-active coping strategies. Rather than relying on medication as a main coping strategy, patients with suspected medication overuse may benefit from training and development of more adaptive self-management strategies (e.g., identification and management of controllable headache triggers, relaxation exercises, effective stress management skills, and activity pacing). Expanding their repertoire of adaptive coping strategies may facilitate reduction of medication use and ultimate improvement in headache.

Headache diaries that record acute medication intake should be used by patients with frequent migraine or other headache types to monitor acute medication use. Careful monitoring of acute medication use by both the patient and the physician is important in the prevention of medication overuse headache. Refer to theHeadache Diary Sheet .

Treatment

Treatment plans for the patient with medication overuse headache should include:

1. Patient education with regard to medication overuse headache. Patients need to understand that:Formulation of a plan for cessation of medication overuse
   1. Acute medication overuse can increase headache frequency.
   2. When medication overuse is stopped, headache may worsen temporarily and patients may experience other withdrawal symptoms.
   3. Many patients will experience a long-term reduction in headache frequency after medication overuse is stopped.
   4. Prophylactic medications may become more effective.
3. Provision of a prophylactic medication
4. A strategy for the treatment of remaining severe headache attacks with limitations on frequency of use (i.e., a triptan for patients with analgesic overuse, DHE for patients with triptan overuse, etc.)
5. Patient follow-up and support

Headache Prophylaxis

Pharmacological prophylaxis should be considered in patients with suspected medication overuse headache, with the prophylactic medication started prior to or during medication withdrawal. Many migraine prophylactics are used (beta-blockers, tricyclics, and others) but topiramate (with the drug titrated slowly to a target dose of 100 mg daily, see migraine prophylaxis section), and OnabotulinumtoxinA (100 to 200 Units injected at intervals of 3 months by clinicians experienced in its use for headache) have the best evidence for efficacy in the setting of chronic migraine with medication overuse.

Stopping Medication Overuse

Withdrawal of the overused medication should be attempted in all patients with suspected medication overuse headache. For most motivated patients, treatment can be carried out in an outpatient setting. A headache diary should be used to ensure that medication withdrawal targets are being met. Refer to the Headache Diary Sheet .

Abrupt withdrawal should be advised for patients with suspected medication overuse headache caused by simple analgesics (acetaminophen, NSAIDs) or triptans, although gradual withdrawal is also an option.

Gradual withdrawal should be advised for patients with suspected medication overuse headache caused by opioids and opioid-containing analgesics.

Referral

Cluster headache is an uncommon condition and specialist advice should be considered early if the patient is not responding well to therapy or unusual medication doses are required.

Effective options for the acute treatment of cluster headache attacks are:

1. Subcutaneous sumatriptan 6 mg

2. Intranasal zolmitriptan 5 mg or sumatriptan 20 mg

3. 100% oxygen at a rate of 12 litres per minute for 15 minutes through a non-rebreathing mask. (Caution is recommended in patients with chronic obstructive pulmonary disease [COPD].)

4. Oral triptans (zolmitriptan 5 mg) have shown some benefit, but are generally less effective.

For prophylaxis of cluster headache:

• Verapamil 240 mg to 480 mg daily is recommended as the drug of first choice. Higher doses can be used if necessary, but when doses above 480 mg are used, electrocardiograms should be done with each dosage increase to monitor for prolonged PR interval and cardiac arrhythmias.

  Possible side effects are bradycardia, ankle edema, constipation, gastrointestinal discomfort, gingival hyperplasia, and dull headache.

• For patients with frequent cluster attacks (several per day), while verapamil prophylaxis is being established, prednisone (60 mg daily for five days, then reduced by 10 mg every 2 days until discontinued) can be given as a transitional therapy at the start of a cluster bout to stop it quickly.

• Lithium (target dose 900 mg to 1,200 mg daily) is a drug of second choice and is used if verapamil is ineffective or contraindicated. Blood levels should be monitored to avoid toxicity and to ensure an adequate dose.

  The major side effects are thyroid dysfunction, tremor, and renal dysfunction.

• Melatonin up to 10 mg daily may be useful in some patients.

• Topiramate can be considered (target dose 100 to 200 mg daily, with a starting dose of 25 mg daily).

  Side effects include cognitive disturbances, paresthesia, and weight loss.

Referral

Patients with hemicrania continua require specialist referral.

Pharmacological Therapy

Indomethacin (25 mg to 75 mg three times a day) will provide headache relief.

Long term use of indomethacin is often problematic because of side effects (gastric irritation and bleeding, and renal dysfunction).

Referral

If the headache history and examination of the neck indicates that neck problems may be playing a significant role in the patient's headache, referral to a musculoskeletal therapist or specialist should be considered.

Exercise

Although there is insufficient evidence to recommend any specific exercise for the treatment of cervicogenic headache, a therapeutic exercise program based upon an assessment by an appropriately trained health professional may be considered.

Cervical Spinal Manipulation

Cervical spinal manipulation, defined as the application of high velocity, low amplitude manual thrusts to the spinal joints slightly beyond the passive range of joint motion, may be considered in the management of patients with cervicogenic headache.

Cervical Spine Mobilization

Cervical spine mobilization, defined as the application of manual force to the spinal joints within the passive range of joint motion that does not involve a thrust, may be considered in the management of patients with cervicogenic headache.

Referral

For patients with headache and symptoms and signs of a temporomandibular disorder (TMD), referral to a therapist or specialist in TMD may be appropriate.

Exercise

A therapeutic exercise program based upon an assessment by an appropriately trained health professional may be considered for patients with TMD.

• The Guideline Development Group (GDG) accepted the original recommendation, which provided a prescriptive direction to perform the action or used the term "effective" to describe it.
• The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, and/or systematic reviews which supported the action.

• The GDG accepted the original recommendation, which provided a prescriptive direction not to perform the action; used the term "ineffective" to describe it; or stated that the evidence does "not support" it.
• The GDG supplemented a recommendation or created a new one, based on their collective professional opinion and/or systematic reviews, which did not support the action.

• The GDG accepted the original recommendation, which did not recommend for or against the action or stated that there was "no evidence," "insufficient or conflicting evidence," or "no good evidence" to support its use.
• The GDG supplemented a recommendation or created a new one, based on their collective professional opinion and/or systematic reviews, which was equivocal with respect to supporting the action.

Frishberg BM, Rosenberg JH, Matchar DB, McCrory DC, Pietrzak MP, et al. Evidence based guidelines in the primary care setting: neuroimaging in patients with non-acute headache. St Paul, MN: US Headache Consortium; 2000. Available from:http://tools.aan.com/professionals/practice/pdfs/gl0088.pdf  (accessed July 3, 2012).

Matchar DB, Young WB, Rosenberg JH, Pietrzak MP, Silberstein SD, et al. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management of acute attacks. St Paul, MN: US Headache Consortium; 2000. Available from: http://tools.aan.com/professionals/practice/pdfs/gl0087.pdf  (accessed July 3, 2012).

Ramadan NM, Silberstein SD, Freitag FG, Gilbert TT, Frishberg BM. Evidence-based guidelines for migraine headache in the primary care setting: pharmacological management for prevention of migraine. St Paul, MN: US Headache Consortium; 2000. Available from: ttp://tools.aan.com/professionals/practice/pdfs/gl0090.pdf  (accessed July 3, 2012).

Campbell JK, Penzien DB, Wall EM. Evidence-based guidelines for migraine headache: behavioral and physical treatments. St Paul, MN: US Headache Consortium; 2000. Available from: http://tools.aan.com/professionals/practice/pdfs/gl0089.pdf  (accessed July 3, 2012).

Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, et al. EFNS guideline on the drug treatment of migraine - revised report of an EFNS task force. European Journal of Neurology 2009;16(9):968-81.

Géraud G, Lantéri-Minet M, Lucas C, Valade D. French Society for the Study of Migraine Headache (SFEMC). French guidelines for the diagnosis and management of migraine in adults and children. Clinical Therapeutics 2004;26(8):1305-18.

Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults. A national clinical guideline. SIGN Publication No. 107. Edinburgh: SIGN; 2008. Available from:http://www.sign.ac.uk/guidelines/fulltext/107/index.html  (accessed July 3, 2012).

May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, et al. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. European Journal of Neurology 2006;13(10):1066-77.

Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J. EFNS guideline on the treatment of tension-type headache - Report of an EFNS task force. European Journal of Neurology 2010;17(11):1318-25.