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Headache, Diagnosis and Treatment of

Guideline Summary

Revision Date: January 2013
Eleventh Edition

Scope and Target Population

Patients age 12 years and older who present with headache. For the purpose of this guideline, pain that primarily involves the back of the neck and only involves the head to a limited extent is not considered a headache. This guideline does not specifically address occipital neuralgia


  1. Increase the accurate diagnosis of primary headaches in patients age 12 years and older.
  2. Increase the percentage of patients with primary headache diagnosis who receive educational materials about headache.
  3. Increase the percentage of patients with primary headache syndrome who receive prophylactic treatment.
  4. Increase the percentage of patients with migraine headache who have improvement in their functional status.
  5. Increase the percentage of patients with migraine headache who have a treatment plan or report adherence to a treatment plan.
  6. Decrease the percentage of patients with migraine headache who are prescribed opiates and barbiturates for the treatment of migraines to less than 5%.
  7. Increase the percentage of patients with migraine headache who have appropriate acute treatment.

Clinical Highlights

  • Headache is diagnosed by history and physical examination with limited need for imaging or laboratory tests.
  • Warning signs of possible disorder other than primary headache:
    - Subacute and/or progressive headaches that worsen over time (months)
    - A new or different headache
    - Any headache of maximum severity at onset
    - Headache of new onset after age 50
    - Persistent headache precipitated by a Valsalva maneuver
    - Evidence such as fever, hypertension, myalgias, weight loss or scalp tenderness suggesting a systemic disorder
    - Presence of neurological signs that may suggest a secondary cause
    - Seizures
  • Migraine-associated symptoms are often misdiagnosed as "sinus headache" by patients and clinicians. Most headaches characterized as "sinus headaches" are migraines.
  • Early treatment of migraines with effective medications improves a variety of outcomes including duration, severity and associated disability.
  • Drug treatment of acute headache should generally not exceed more than two days per week on a regular basis. More frequent treatment other than this may result in medication-overuse chronic daily headaches.
  • Inability to work or carry out usual activities during a headache is an important issue for migraineurs.
  • Prophylactic therapy should be considered for all patients.
  • Migraines occurring in association with menses and not responsive to standard cyclic prophylaxis may respond to hormonal prophylaxis with the use of estradiol patches, creams or estrogen-containing contraceptives.
  • Women who have migraines with aura have a substantially higher risk of stroke with the use of estrogen-containing contraceptive compared to those without migraines. Headaches occurring during perimenopause or after menopause may respond to hormonal therapy.
  • Most prophylactic medications should be started in a low dose and titrated to a therapeutic dose to minimize side effects and maintained at target dose for 8-12 weeks to obtain maximum efficacy.