Migraine
NICE clinical guideline [CG150] Headaches in over 12s: diagnosis and management. Last updated: Jun 2025.
NICE CKS Migraine. Last revised: Feb 2024.
Guidelines
Headache Red Flags
If headache and ANY of the following red flags, consider the need for further investigations and/or referral:
| Category | Red Flag | Explanation |
|---|---|---|
| Infection / Inflammation | Worsening headache with fever | Suggests possible central nervous system infection (e.g., meningitis, encephalitis) or inflammatory disease. |
| Symptoms suggestive of giant cell arteritis (e.g., jaw claudication, age >50, visual symptoms) | Points to vasculitis with risk of vision loss or stroke. | |
| Immunocompromised status (HIV, immunosuppressive drugs) | Increases risk for opportunistic infections and neoplastic processes. | |
| Vascular / Haemorrhagic | Sudden-onset headache reaching maximum intensity within 5 minutes (thunderclap) | Characteristic of subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, or other acute vascular events. |
| New-onset neurological deficit | May indicate stroke, intracranial mass, encephalitis, or other structural or metabolic brain disorders. | |
| New cognitive dysfunction, personality change, or impaired level of consciousness | Suggests stroke, intracranial mass, encephalitis, or other significant brain pathology. | |
| Raised Intracranial Pressure / Structural | Headache triggered by cough, valsalva maneuver, sneeze, or exercise | Can be a sign of increased intracranial pressure (e.g., due to intracranial mass). |
| Vomiting without other clear cause | May reflect increased intracranial pressure or mass effect. | |
| Substantial change in headache characteristics | May signal a new secondary process, such as neoplasm or infection. | |
| Intracranial Hypotension | Orthostatic headache | Typical of intracranial hypotension, often due to CSF leak. |
| Trauma-related | Recent head trauma (within 3 months) | Raises concern for traumatic intracranial hemorrhage (e.g., subdural haematoma). |
| Oncology-related | Age <20 with history of malignancy | Raises suspicion for metastatic or recurrent disease affecting the CNS. |
| History of malignancy known to metastasize to the brain | Increases risk for intracranial metastases. | |
| Ocular Emergencies | Symptoms/signs of acute narrow-angle glaucoma (painful red eye, visual loss) | Requires urgent ophthalmologic evaluation. |
Investigation and Diagnosis
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 |
| Pain intensity | Moderate or severe |
| Duration | 4-72 hours in adults, and 1-72 hours in younger patients |
| Effect on activities | Aggravated by, or causes avoidance of ADLs |
| Other symptoms |
|
| Aura | Aura can occur without or with headache:
Typical aura symptoms:
|
Notable differences in paediatric migraine:[Ref1][Ref 2]
- Location
- Often bilateral (more commonly unilateral in adults).
- Frequently frontal or temporal rather than hemicranial.
- Character
- Pounding or throbbing, but in younger children may be less distinctly pulsatile.
- Duration
- Usually shorter, often lasting 1–48 hours, compared to 4–72 hours in adults.
- Associated symptoms
- More likely to experience prominent gastrointestinal symptoms, especially vomiting and nausea.
Management
Adults
Acute Management
1st line: combination therapy of oral triptan (1st line: sumatriptan) + NSAID / paracetamol
- If the person prefers taking 1 drug → monotherapy of paracetamol / aspirin 900mg / NSAID / triptan
2nd line:
- Metoclopramide / 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 antiemetic in addition to other acute treatment for migraine, even in the absence of nausea and vomiting
Preventive Treatment
Only consider preventive/prophylactic 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 headache due to frequent use of acute drugs
- It is essential to rule out medication overuse headache before preventive treatment is initiated
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
Young People (12-17 y/o)
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 a specialist
Do NOT offer aspirin in those <16 yo due to risk of Reye’s syndrome.
Pregnant / Breastfeeding Women
Acute management:
- 1st line: non-pharmacological measures (e.g. relaxation technique, CBT, avoidance of triggers)
- 2nd line: paracetamol
- 3rd line: ibuprofen (if <20 weeks gestation) or triptan
Metoclopramide and prochlorperazine can be used as short-term treatment options for nausea and vomiting in pregnancy.
Preventive treatment: specialist advise should be sought (as in children)
Do NOT offer aspirin (or opioids) for the acute management of migraines in pregnancy or breastfeeding.
References
Original Guideline