Diagnosis of headaches

A NICE pathway brings together all NICE guidance, quality

standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
online. This pdf version gives you a single pathway diagram and
uses numbering to link the boxes in the diagram to the associated
recommendations.
To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/headaches
Pathway last updated: 23 June 2015. To see details of any updates to this pathway since its launch,
visit: About this Pathway. For information on the NICE guidance used to create this path, see:
Sources.
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Diagnosis of headaches

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Diagnosis of headaches

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Diagnosis of headaches

No additional information

Tension-type headache, migraine (with or without aura) and cluster

headache

Diagnose tension-type headache, migraine or cluster headache according to the headache

features shown in the diagnosis table for tension-type headache, migraine and cluster
headache [See page 5] in this pathway.
Migraine (with or without aura)
Suspect aura in people who present with or without headache and with neurological symptoms
that:
are fully reversible and
develop gradually, either alone or in succession, over at least 5 minutes and
last for 560 minutes.
Diagnose migraine with aura in people who present with or without headache and with one or
more of the following typical aura symptoms that meet the criteria listed in 'When to suspect
aura' above.
Visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or
negative (for example, partial loss of vision).
Sensory symptoms that may be positive (for example, pins and needles) and/or negative
(for example, numbness).
Speech disturbance.
Consider further investigations and/or referral for people who present with or without migraine
headache and with any of the following atypical aura symptoms that meet the criteria listed in
'When to suspect aura' above.
Motor weakness.
Double vision.
Visual symptoms affecting only one eye.
Poor balance.
Decreased level of consciousness.
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Diagnosis of headaches

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Quality standards
The following quality statement is relevant to this part of the pathway.
1.

Classification of headache type

Resources
The following implementation tool is relevant to this part of the pathway.
Headaches: diagnosis poster

Menstrual-related migraine

Suspect menstrual-related migraine in women and girls whose migraine occurs predominantly
between 2 days before and 3 days after the start of menstruation in at least 2 out of 3
consecutive menstrual cycles.
Diagnose menstrual-related migraine using a headache diary for at least 2 menstrual cycles.
For more information on using a headache diary see 'Headache diaries' under assessment in
this pathway.

Medication overuse headache

Be alert to the possibility of medication overuse headache in people whose headache

developed or worsened while they were taking the following drugs for 3 months or more:
triptans, opioids, ergots or combination analgesic medications on 10 days per month or
more or
paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per
month or more.

Management of headaches

See Headaches / Management of headaches

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NICE Pathways

Diagnosis of headaches

Diagnosis table for tension-type headache, migraine and cluster headache

Headache
feature

Tension-type
headache

Migraine (with or without

aura)

Cluster headache

Bilateral

Unilateral or bilateral

Unilateral (around the

eye, above the eye and
along the side of the
head/face)

Pain
quality

Pressing/tightening
(non-pulsating)

Pulsing (throbbing or
banging in young people
aged 1217 years)

Variable (can be sharp,

boring, burning,
throbbing or tightening)

Pain
intensity

Mild or moderate

Moderate or severe

Severe or very severe

Effect on
activities

Not aggravated by
routine activities of
daily living

Aggravated by, or causes

avoidance of, routine
activities of daily living

Restlessness or agitation

Pain
location1

Unusual sensitivity to light

and/or sound or nausea
and/or vomiting
Aura2
Other
symptoms

None

Aura symptoms can occur

with or without headache
and:
are fully reversible
develop over at least 5
minutes

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On the same side as the

headache:
red and/or watery
eye
nasal congestion
and/or runny nose
swollen eyelid
forehead and facial
sweating
constricted pupil
and/or drooping
eyelid

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NICE Pathways

Diagnosis of headaches

last 560 minutes.

Typical aura symptoms
include visual symptoms
such as flickering lights,
spots or lines and/or partial
loss of vision; sensory
symptoms such as
numbness and/or pins and
needles; and/or speech
disturbance.

Duration
of
headache

472 hours in adults

30 minutescontinuous

15 days
Frequency Less than per month
of
15 days
or more for
headache per month more than
3 months

Chronic
Episodic
tensiontensionDiagnosis
type
type
headache headache5

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172 hours in young

people aged 1217
years

15180 minutes

1 every
other day
to 8 per

1 every
other day to
8 per day3,
with a
continuous

15 days per
Less than
month or
15 days per
day3, with
4
more for more
4 remission
month
remission
than 3 months
less than 1
more than
month in a
1 month
12-month
period

Episodic
migraine
(with or
without
aura)

Chronic
migraine
(with or
without

Episodic
cluster
headache

Chronic
cluster
headache

aura)6

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Diagnosis of headaches

NICE Pathways

Headache pain can be felt in the head, face or neck.

For further information on diagnosis of migraine with aura see tension-type headache,
migraine (with or without aura) and cluster headache [See page 3] in this pathway.
3

The frequency of recurrent headaches during a cluster headache bout.

The pain-free period between cluster headache bouts.

Chronic migraine and chronic tension-type headache commonly overlap. If there are any
features of migraine, diagnose chronic migraine.
6

NICE has developed technology appraisal guidance on Botulinum toxin type A for the
prevention of headaches in adults with chronic migraine (headaches on at least 15 days per
month of which at least 8 days are with migraine). See prophylactic treatment in this pathway.

Glossary
Acute narrow-angle glaucoma
An uncommon eye condition that results from blockage of the drainage of fluid from the eye.
Symptoms of acute glaucoma may include headache with a painful red eye and misty vision or
haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster
headache by the presence of a semi-dilated pupil compared with the presence of a constricted
pupil in cluster headache.
Bout of cluster headache
The duration over which recurrent cluster headaches occur, usually lasting weeks or months.
Headaches occur from once every other day to 8 times per day
CNS
Central nervous system

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Diagnosis of headaches

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Giant cell arteritis

Also known as temporal arteritis, giant cell arteritis is characterised by the inflammation of the
walls of medium and large arteries. Branches of the carotid artery and the ophthalmic artery are
preferentially involved, giving rise to symptoms of headache, visual disturbances and jaw
claudication
NSAID
Non-steroidal anti-inflammatory drug
Positive diagnosis
A diagnosis based on the typical clinical picture that does not require any further investigations
to exclude alternative explanations for a patient's symptoms
Young people
People aged 12 to 17 years

Sources
Headaches (2012) NICE guideline CG150

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

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Diagnosis of headaches

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Copyright
Copyright National Institute for Health and Care Excellence 2015. All rights reserved. NICE
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or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE
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nice@nice.org.uk
0845 003 7781

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