Red Flags
- Thunderclap headache (peak severity within 5 min) — same-day CT and CSF; rule out subarachnoid haemorrhage and reversible cerebral vasoconstriction[1]
- Headache with focal neurology, papilloedema, fever, immunocompromise, or recent head injury — emergency brain imaging[1]
- First headache after age 50, or change in pattern after age 50 — exclude giant cell arteritis (ESR/CRP, temporal artery biopsy)[1]
- Medication overuse headache (≥10 days/month triptan, opioid or combination analgesic; ≥15 days/month simple analgesic) — withdraw overused agent and start preventive[1]
First-line treatment
Interventions
- Diagnosis using ICHD-3 criteria[1]Migraine without aura: ≥5 attacks lasting 4–72 h with ≥2 of unilateral, pulsating, moderate-severe, aggravated by activity + nausea/vomiting or photophobia/phonophobia. Tension-type, cluster, and medication-overuse have distinct criteria
- Trigger identification and lifestyle modification[1]Regular sleep, hydration, meals; reduce alcohol and caffeine; aerobic exercise; stress management. Use diary to identify individual triggers
- Withdraw overused acute medication for medication-overuse headache[1]Abrupt or graded withdrawal of overused agent under specialist guidance; symptomatic worsening for 1–2 weeks then improvement; start preventive concurrently
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Sumatriptan or rizatriptan (acute migraine)[1] | Triptan / 5-HT1B/1D agonist | Sumatriptan 50–100 mg PO at headache onset; nasal 10–20 mg; SC 6 mg for severe attacks. Rizatriptan 10 mg PO; up to 2 doses per attack | Adolescents ≥12: sumatriptan nasal 10 mg or rizatriptan ODT 5–10 mg | Most effective for moderate-severe migraine; combine with paracetamol or NSAID; max 9 days/month to prevent medication-overuse headache; contraindicated in CAD, uncontrolled HTN, hemiplegic migraine |
| Naproxen or ibuprofen (acute migraine and tension-type)[1] | NSAID | Naproxen 500 mg PO at onset, may repeat 250 mg in 6–8 h; ibuprofen 400–600 mg PO at onset | Ibuprofen 7–10 mg/kg/dose | First-line in mild–moderate attack; combine with antiemetic for nausea; max 14 days/month to avoid medication-overuse |
| Paracetamol (acute migraine and tension-type)[1] | Analgesic / antipyretic | 1 g PO at onset, max 4 g/day | 15 mg/kg/dose, max 60 mg/kg/day | Widely available alternative or combination with NSAID; max 14 days/month |
| Metoclopramide or prochlorperazine (acute nausea)[1] | Antiemetic | Metoclopramide 10 mg PO/IV/IM at onset; prochlorperazine 5–10 mg PO or 12.5 mg IM | Cyclizine if metoclopramide contraindicated (extrapyramidal risk) | Adjunct to triptan or NSAID; monitor extrapyramidal effects in young women |
| Sumatriptan SC + high-flow oxygen (acute cluster headache)[1] | Triptan + oxygen therapy | Sumatriptan 6 mg SC at onset, may repeat once after 1 h; 100% O2 12–15 L/min via non-rebreather × 15 min | — | First-line for cluster headache; tachycardia and chest tightness common; avoid in cardiovascular disease |
| Verapamil (cluster prophylaxis)[1] | Calcium channel blocker | 240–960 mg/day in divided doses; baseline ECG and PR interval monitoring | — | First-line preventive for episodic and chronic cluster headache; specialist initiation; bridge with steroid or galcanezumab during titration |
| Amitriptyline (chronic tension-type headache)[1] | Tricyclic antidepressant | 10–25 mg PO at night; titrate to 75 mg as tolerated | — | First-line preventive for frequent tension-type headache; first-line for migraine in those with comorbid depression or insomnia |
Sumatriptan or rizatriptan (acute migraine)[1]
Triptan / 5-HT1B/1D agonist
- Adult
- Sumatriptan 50–100 mg PO at headache onset; nasal 10–20 mg; SC 6 mg for severe attacks. Rizatriptan 10 mg PO; up to 2 doses per attack
- Paediatric
- Adolescents ≥12: sumatriptan nasal 10 mg or rizatriptan ODT 5–10 mg
Most effective for moderate-severe migraine; combine with paracetamol or NSAID; max 9 days/month to prevent medication-overuse headache; contraindicated in CAD, uncontrolled HTN, hemiplegic migraine
Naproxen or ibuprofen (acute migraine and tension-type)[1]
NSAID
- Adult
- Naproxen 500 mg PO at onset, may repeat 250 mg in 6–8 h; ibuprofen 400–600 mg PO at onset
- Paediatric
- Ibuprofen 7–10 mg/kg/dose
First-line in mild–moderate attack; combine with antiemetic for nausea; max 14 days/month to avoid medication-overuse
Paracetamol (acute migraine and tension-type)[1]
Analgesic / antipyretic
- Adult
- 1 g PO at onset, max 4 g/day
- Paediatric
- 15 mg/kg/dose, max 60 mg/kg/day
Widely available alternative or combination with NSAID; max 14 days/month
Metoclopramide or prochlorperazine (acute nausea)[1]
Antiemetic
- Adult
- Metoclopramide 10 mg PO/IV/IM at onset; prochlorperazine 5–10 mg PO or 12.5 mg IM
- Paediatric
- Cyclizine if metoclopramide contraindicated (extrapyramidal risk)
Adjunct to triptan or NSAID; monitor extrapyramidal effects in young women
Sumatriptan SC + high-flow oxygen (acute cluster headache)[1]
Triptan + oxygen therapy
- Adult
- Sumatriptan 6 mg SC at onset, may repeat once after 1 h; 100% O2 12–15 L/min via non-rebreather × 15 min
- Paediatric
- —
First-line for cluster headache; tachycardia and chest tightness common; avoid in cardiovascular disease
Verapamil (cluster prophylaxis)[1]
Calcium channel blocker
- Adult
- 240–960 mg/day in divided doses; baseline ECG and PR interval monitoring
- Paediatric
- —
First-line preventive for episodic and chronic cluster headache; specialist initiation; bridge with steroid or galcanezumab during titration
Amitriptyline (chronic tension-type headache)[1]
Tricyclic antidepressant
- Adult
- 10–25 mg PO at night; titrate to 75 mg as tolerated
- Paediatric
- —
First-line preventive for frequent tension-type headache; first-line for migraine in those with comorbid depression or insomnia
Safety-net
- Track headache and analgesic days in a diary for ≥4 weeks before next review — gives you and your clinician objective response data[1]
- If a triptan or analgesic stops working — do not increase the dose; that is the warning sign of medication-overuse headache. Speak to your clinician[1]
- Sudden severe headache, fever with neck stiffness, weakness, vision change, or new symptoms after age 50 — call emergency services or attend A&E[1]
Referral criteria
- Headache with red flag featuresEmergency department / neurology[1]
- Cluster headache (acute or preventive uncertainty)Neurology / headache specialist[1]
- Migraine refractory to two adequate preventives, chronic migraine, or persistent medication-overuse headacheNeurology / headache specialist for CGRP-targeted therapy or onabotulinumtoxin A[1]
- Suspected giant cell arteritisRheumatology same-day with steroid initiation[1]
Clinical summary
Diagnosis and acute management of migraine, tension-type headache, cluster headache, and medication-overuse headache in adults and adolescents ≥12 years.