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Migraine

NICE clinical guideline [CG150] Headaches in over 12s: diagnosis and management. Last updated: Jun 2025. NICE CKS Migraine. Last revised: Feb 2024.

Guidelines

If headache and ANY of the following, consider the need for further investigations and/or referral:

  • worsening headache with fever

  • sudden‑onset headache reaching maximum intensity within 5 minutes

  • new‑onset neurological deficit

  • new‑onset cognitive dysfunction

  • change in personality

  • impaired level of consciousness

  • recent (typically within the past 3 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


If new-onset headache and ANY of the following, consider the need for further investigations and/or referral:

  • Immunocompromised (e.g. HIV, use of immunosuppressive drugs)
  • <20 y/o + history of malignancy
  • History of malignancy known to metastasise to the brain
  • Vomiting without other obvious causes

NICE recommends considering the use of a headache diary for at least 8 weeks to aid the diagnosis of primary headaches. The person should record the following:
  • Frequency, duration and severity of headaches
  • Any associated symptoms
  • Possible precipitants
  • Relationship of headaches to menstruation
  • All medications taken to relieve headaches
 

Do not refer people diagnosed with tension‑type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.


NICE recommends clinical diagnosis, according to the following headache features:
 
Headache feature Seen in migraine +/- aura
Pain location Unilateral or bilateral
Pain quality Pulsating or throbbing (in younger patients)
Pain intensity Moderate or severe
Duration 4-72 hours in adults, and 1-72 hours in younger patients
Effect on activities Aggravated by, or cause avoidance of ADLsActivities of daily living
Other symptoms
  • Nausea and/or vomiting
  • Photosensitivity
  • Phonosensitivity
Aura Aura can occur without or without headache:
  • Develop over at least 5 min
  • Last 5-60 min
  • Fully reversible

Typical aura symptoms:
  • Visual symptoms (most common) - flickering lights, spots or lines, partial loss of vision
  • Sensory symptoms - numbness, paraesthesia
  • Speech disturbance

1st line: combination therapy of oral triptan (sumtriptan first choice) + NSAID / paracetamol
  • If the person prefers taking 1 drug → monotherapy of paracetamol / aspirin 900mg / NSAID / triptan

2nd line:
  • Metoclopramie / prochlorperazine (non-oral preparation)
  • Consider adding non-oral NSAID or triptan (if not been tried)

3rd line: rimegepant (CGRP inhibitor), if
  • At least triptans were tried and not effective, or
  • Triptans were inappropriate and NSAIDs + paracetamol were not effective

Consider an anti‑emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting

Only consider preventive treatment if
  • Migraine attacks have a significant impact on quality of life and daily function
  • Acute treatments are ineffective or contraindicated
  • At risk of medication overuse headahce due to frequent use of acute drugs

1st line (any of the following):
  • Propranolol (avoid in asthma)
  • Topiramate (contraindicated in pregnancy and avoid in women of childbearing age)
  • Amitriptyline​​​​​

2nd line: acupuncture over 5-8 weeks for up to 10 sessions

3rd line options: 
  • CGRP inhibitors if
    • 3 preventive medications did not work or not appropriate, and
    • In adults with ≥4 migraine days per month
 
  • IM botulinum toxin type A if
    • 3 preventive medications did not work or not appropriate

Acute management:
  • 1st line: monotherapy of paracetamol or NSAID 
  • 2nd line: nasal triptan (NB oral triptan is not licensed for use <18 y/o)
  • 3rd line: combination therapy of nasal triptan + paracetamol / NSAID

Preventive treatment should only be started by specialsit.

 

Do not offer aspirin in those <16 yo due to risk of Reye's syndrome

Acute management:
  • 1st line: non-pharmacological measures (e.g. relaxation technique, CBTCognitive behavioural therapy, avoidance of triggers)
  • 2nd line: paracetamol
  • 3rd line: ibuprofen only if <20 weeks gestation

Metoclopramide and prochlorperazine can be used as short-term treatment options for nausea and vomiting in pregnancy.

References

Author: Adams Lau
Reviewer:
Last edited: 18/07/25