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NICE has issued a significant update to Clinical Guideline CG150, focusing on the diagnosis and management of headaches in individuals aged 12 years and older. This comprehensive guideline addresses various headache disorders, including tension-type headaches, migraines (with or without aura), cluster headaches, and medication overuse headaches. The 2025 revision introduces critical changes, particularly in the prophylactic treatment of migraines, reflecting new safety data and regulatory advice.
Key updates include:
Revised Recommendations for Migraine Prophylaxis: The guideline now advises healthcare professionals to consider propranolol, topiramate, or amitriptyline for migraine prevention, rather than offering propranolol or topiramate as first-line options. This change accounts for updated safety profiles and regulatory guidance.
Safety Considerations for Propranolol: Due to the potential risk of self-harm in individuals with depression, caution is advised when prescribing propranolol. Healthcare providers should assess the risk of toxicity and rapid deterioration in overdose situations
Topiramate Use Restrictions: Topiramate is contraindicated for migraine prophylaxis during pregnancy and in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met.
Inclusion of New Therapeutic Options: The guideline incorporates recommendations for newer treatments, such as calcitonin gene-related peptide (CGRP) inhibitors, including rimegepant, atogepant, eptinezumab, fremanezumab, erenumab, and galcanezumab, for patients with episodic or chronic migraines unresponsive to at least three preventive medicines.
| Subsection | Recommendation | Key Details |
|---|---|---|
| 1.1.1 | Evaluate headache + red flags |
- Worsening headache with fever - Sudden-onset, peak intensity in <5 min - New neurological deficit / cognitive changes - Personality change, impaired consciousness - Recent head trauma (<3 months) - Triggered by cough, valsalva, sneeze, exercise - Orthostatic headache - Suspected GCA - Acute narrow angle glaucoma signs - Substantial change in headache pattern |
| 1.1.2 | Investigate/refer if new headache + risks |
- Immunocompromised (e.g. HIV, immunosuppressants) - <20 years old with malignancy history - Malignancy known to metastasise to brain - Unexplained vomiting |
| 1.1.3 | Use headache diary | Supports diagnosis of primary headaches ↑ |
| 1.1.4 | Diary specifics |
- Frequency, duration, severity - Associated symptoms - Medications (Rx and OTC) - Triggers - Relation to menstruation |
| Aspect | Details |
|---|---|
| Pain Location | Unilateral or bilateral |
| Pain Quality | Pulsating (throbbing or banging – especially in those aged 12–17) |
| Pain Intensity | Moderate or severe |
| Effect on Activities | Aggravated by or leads to avoidance of routine activities |
| Other Symptoms | Sensitivity to light (photophobia) and/or sound (phonophobia), nausea and/or vomiting |
| Duration |
Adults: 4 to 72 hours Young people (12–17 years): 1 to 72 hours |
| Frequency |
Episodic: <15 days/month Chronic: ≥15 days/month for >3 months with ≥8 days showing migraine features |
| Aura Features |
- Fully reversible neurological symptoms - Develop gradually over ≥5 minutes (alone or in succession) - Last 5–60 minutes |
| Typical Aura Symptoms |
- Visual: flickering lights, spots, lines, partial loss of vision - Sensory: pins and needles, numbness - Speech disturbance |
| Atypical Aura |
Consider referral if aura includes: - Motor weakness - Double vision - Visual symptoms in one eye - Poor balance - Reduced consciousness |
| Menstrual-related Migraine |
- Suspect if symptoms occur from 2 days before to 3 days after menstruation in ≥2/3 cycles - Confirm diagnosis using a headache diary over ≥2 menstrual cycles |
| Treatment Strategy | Recommendation |
|---|---|
| Combination Therapy |
Offer oral triptan + NSAID or triptan + paracetamol. In ages 12–17, consider nasal triptan. |
| Monotherapy Option |
Consider oral triptan, NSAID, aspirin (900 mg), or paracetamol. Avoid aspirin in under 16s due to Reye’s syndrome risk. |
| Triptan Selection | Start with the lowest-cost triptan; if ineffective, try alternatives. |
| Add-On Anti-Emetic | Consider anti-emetic (e.g., metoclopramide, prochlorperazine) even in the absence of nausea or vomiting. |
| Non-Oral Options |
If oral/nasal preparations are ineffective or not tolerated: - Use non-oral metoclopramide or prochlorperazine - Add non-oral NSAID or triptan if not yet tried |
| Advanced Therapy |
Offer rimegepant (sublingual CGRP inhibitor) if: - ≥2 triptans failed or not tolerated, and - NSAIDs and paracetamol were also ineffective (NICE TA919, 2023) |
| Avoid These | Do not offer ergots or opioids. 🚫 |
💊 Note: As of June 2025, most triptans are off-label in under-18s (except nasal sumatriptan). Buccal prochlorperazine is the only licensed non-oral anti-emetic for migraine.
| Step | Action |
|---|---|
| 1 | Discuss with patient: preferences, comorbidities, risk of adverse effects, and impact on life quality. |
| 2 |
First-line options: - Propranolol: use caution if risk of self-harm. - Topiramate: contraindicated in pregnancy unless Pregnancy Prevention Programme met. - Amitriptyline: follow NICE guidance on withdrawal/dependence. |
| 3 | If one option fails or is not tolerated, try the others unless contraindicated. |
| 4 | Do not offer gabapentin. |
| Option | When to Consider |
|---|---|
| Acupuncture | Up to 10 sessions over 5–8 weeks; if first-line options not suitable or ineffective. |
| CGRP Inhibitors |
If ≥3 preventives failed/not tolerated: - Rimegepant (TA906): 4–14 attacks/month. - Atogepant (TA973), Eptinezumab (TA871), Fremanezumab (TA764), Erenumab (TA682), Galcanezumab (TA659): ≥4 migraine days/month. |
| Botulinum toxin A (TA260) |
For chronic migraine (≥15 headache days/month, ≥8 migraine days). Must have failed ≥3 preventives. Ensure no medication overuse. |
| Review Timeline | Criteria |
|---|---|
| 3–6 months | Assess need for continued prophylaxis. |
| CGRP Inhibitors | Stop after 12 weeks if: - <50% reduction in episodic migraine - <30% reduction in chronic migraine |
| Botulinum Toxin A |
Stop if: - <30% reduction in headache days after 2 cycles - Changed to episodic migraine for 3 consecutive months |
| Scenario | Recommendation |
|---|---|
| Ongoing effective prophylaxis | Continue current regimen. |
| Menstrual-related migraine | Consider frovatriptan or zolmitriptan during predicted migraine periods (off-label). |
| Migraine with aura | Do not routinely offer combined hormonal contraceptives for contraception. |
| Aspect | Details |
|---|---|
| Pain Location | Bilateral (can involve head, face, or neck) |
| Pain Quality | Pressing/tightening (non-pulsating) |
| Pain Intensity | Mild or moderate |
| Effect on Activities | Not aggravated by routine daily activities |
| Other Symptoms | None |
| Duration | 30 minutes to continuous |
| Frequency |
Episodic: <15 days/month Chronic: ≥15 days/month for >3 months |
| Type | Recommendation |
|---|---|
| Acute Treatment |
Consider aspirin, paracetamol, or an NSAID, based on preference, comorbidities, and risk. Do not offer opioids. 🚫 |
| Chronic Prophylaxis | Consider up to 10 sessions of acupuncture over 5–8 weeks. 🎯 |
| Aspect | Details |
|---|---|
| Pain Location | Unilateral (around the eye, above the eye, along the side of head/face) |
| Pain Quality | Variable (sharp, boring, burning, throbbing, or tightening) |
| Pain Intensity | Severe or very severe |
| Effect on Activities | Restlessness or agitation |
| Other Symptoms | On the same side as pain: red/watery eye, nasal congestion/runny nose, swollen eyelid, facial sweating, constricted pupil, drooping eyelid |
| Duration | 15 to 180 minutes |
| Frequency |
Episodic: 1 every other day to 8 per day, pain-free ≥1 month Chronic: same frequency, pain-free <1 month in 12 months |
| Cluster Bout | Lasts weeks to months; high-frequency recurrence pattern |
| Recommendation | Notes |
|---|---|
| Discuss neuroimaging at first episode | Involve GPwSI or neurologist |
| Offer oxygen and/or subcutaneous or nasal triptan | Nasal/subcutaneous triptans are off-label in under-18s; nasal forms unlicensed in UK as of June 2025 |
| Oxygen use details | 100% oxygen, ≥12 L/min, non-rebreathing mask with reservoir bag; arrange home/ambulatory supply |
| Ensure adequate supply of triptans | Dose should reflect cluster pattern and max manufacturer-recommended daily limits |
| Avoid: paracetamol, NSAIDs, opioids, ergots, oral triptans | Not effective for cluster headache |
| Recommendation | Notes |
|---|---|
| Consider verapamil during bouts | Off-label use; requires ECG monitoring; seek specialist advice if unfamiliar |
| Refer if unresponsive to verapamil or during pregnancy | Specialist input essential for non-responders and pregnancy-related management |
| Criteria | Details |
|---|---|
| Suspect MOH if headaches worsen while taking: |
- Triptans, opioids, ergots, or combination analgesics on ≥10 days/month for ≥3 months - Paracetamol, aspirin, or NSAIDs (alone or combined) on ≥15 days/month for ≥3 months |
| Step | Action |
|---|---|
| 1 | Explain that MOH is treated by stopping the overused medication. |
| 2 | Advise abrupt withdrawal of all overused medications for at least 1 month. |
| 3 |
Warn about short-term worsening of headache and potential withdrawal symptoms. Provide close follow-up and support. |
| 4 | Consider starting prophylactic treatment for the primary headache disorder. |
| 5 | Do not routinely offer inpatient withdrawal. |
| 6 |
Consider referral or inpatient withdrawal if: - Strong opioids are used - Relevant comorbidities exist - Previous withdrawal attempts were unsuccessful |
| 7 | Review diagnosis and management plan after 4–8 weeks. |
Reference : https://www.nice.org.uk/guidance/cg150/chapter/Recommendations
