- Chronic migraine (>15 days migraine/month/for 3 consecutive months) in whom at least 4 prophylactic agents have been used at therapeutic doses for at least 3 months each and analgesia over use has been addressed.
- Please provide a note of previously trialled prophylactic treatments, including duration of use and dose reached.
- Please note, advice may be given to trial an oral CGRP (as below) prior to accepting referral
- Cluster headache / trigeminal autonomic cephalalgias
- Recurrent thunderclap headaches (acute onset thunderclap should be referred to medicine)
- Idiopathic intracranial hypertension.
Headache
Who to Refer
Advice Requests for Oral CGRPs
- Oral CGRPs are now available for patients with both episodic migraine occurring >4 days/month and for patients with chronic migraine. Patients must have trialled at least 4 prophylactic agents and analgesia over use should be addressed. All patients require to keep a headache diary for 1 month as a baseline prior to commencing treatment. Further details on Migraine Prophylaxis page.
- If you consider a patient to be eligible or wish to discuss, please contact Neurology via SciGateway for advice
Who not to Refer
- Headache complicated by analgesia overuse
- Tension type / cervicogenic headaches
Chronic headache
Patient management
For specific management of headache syndromes please see below tabs:
- In managing chronic headache, please consider addressing any other contributory components of chronic pain (e.g. insomnia or low mood; see also pain services RefGuide and 'Chronic Daily Headache' patient information leaflet .
- Analgesia over use, if patients are using analgesia >10 days per month it is likely there is an element of analgesia over-use contributing and should be addressed (please see ‘other headache types’ below). This is most commonly seen with codeine and other opiate analgesics.
Patient management
- Patients should be encouraged to review self-management of migraine with lifestyle advice via Migraine Trust
- Patient expectations should be managed: a reduction of 30-50% in headache severity or frequency is considered a successful treatment. In order to monitor response, patients should be provided with a headache diary.
- If patients do not wish to take prophylactic treatment for episodic migraine there is nothing else we have access to. Patients should be encouraged to regulate sleep pattern and review lifestyle factors. They may wish to consider alternative therapies such as Riboflavin and magnesium (however they do not have the support of SIGN) or acupuncture (limited evidence).
For specific management of headache syndromes please see below tabs: