Intended for healthcare professionals

Practice Guidelines

Diagnosis and management of headaches in young people and adults: summary of NICE guidance

BMJ 2012; 345 doi: (Published 19 September 2012) Cite this as: BMJ 2012;345:e5765
  1. Serena Carville, senior research fellow and project manager1,
  2. Smita Padhi, research fellow1,
  3. Tim Reason, statistician and health economist1,
  4. Martin Underwood, professor of primary care research2
  5. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Division of Health Science, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
  1. Correspondence to: M Underwood m.underwood{at}

Headaches are a common problem that many clinicians in primary and secondary care find difficult to treat.1 2 Once the serious causes of headache have been excluded (such as infection, tumour, bleeding, and arteritis), the major health and social burden of headaches can be attributed to primary headache disorders (cluster headache, migraine, and tension-type headache) and headache caused by the overuse of medications. Straightforward advice is needed for anyone working in the NHS on the diagnosis and treatment of these common disorders and the prevention of medication overuse headache.

This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the diagnosis and management of headaches in young people and adults.3


NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Assessment: indications for considering additional investigation

  • Evaluate people who present with headache and any of the following features, and consider the need for further investigations or referral (or both):

    • -Worsening headache with fever

    • -Sudden onset headache that reaches maximum intensity within five minutes

    • -New onset neurological deficit

    • -New onset cognitive dysfunction

    • -Change in personality

    • -Impaired level of consciousness

    • -Recent (typically within the past three 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.

[All based on the experience and opinion of the Guideline Development Group (GDG)]

  • Consider further investigations …

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