Diagnosis and management of headache in adults: summary of SIGN guideline

doi:10.1136/bmj.a2329

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C W Duncan, consultant neurologist1,
D P B Watson, general practitioner2,
A Stein, programme manager 3
on behalf of the Guideline Development Group

¹Aberdeen Royal Infirmary, Aberdeen
²Hamilton Medical Group, Aberdeen
³Scottish Intercollegiate Guidelines Network, Edinburgh EH7 5EA

Correspondence to: A Stein ailsa.stein{at}nhs.net

Why read this summary?

Headache is common and has a lifetime prevalence of over 90% in the United Kingdom.1 It accounts for 4.4% of consultations in primary care2 and 30% of neurology outpatient consultations.3 4 Healthcare professionals find diagnosis and management of headache difficult and they worry about missing rare, serious causes.2 5 This article summarises the most recent recommendations from the Scottish Intercollegiate Guidelines Network (SIGN) on the diagnosis and management of headache in adults.6

Recommendations

SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”) based on the clinical experience of the guideline development group is also indicated (as GPP).

Explanation of SIGN grades of recommendations.

History and examination

A good history is the key to diagnosis. Examination is usually normal in patients with primary headache, such as migraine, tension-type headache, and cluster headache.

Consider a diagnosis of migraine in patients with recurrent severe disabling headaches associated with nausea and sensitivity to light, and with a normal neurological examination (C). Migraine is characteristically unilateral, pulsating, builds up over minutes to hours, and is aggravated by routine physical activity.7 It is the most common type of severe primary headache; it causes considerable disability8 and is misdiagnosed in half of cases, usually as tension-type headache or sinus headache.9 10 11 12
Consider a diagnosis of tension-type headache in patients with recurrent, non-disabling bilateral headache and a normal neurological examination (C). Although tension-type headache is less burdensome than migraine to the individual patient, its higher prevalence results in greater societal burden and as many lost days from work.13
Consider the diagnosis of a trigeminal autonomic cephalalgia …