Primary headache disorders

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.

References

1.NICE Clinical Guideline CG150 — Headaches in Over 12s: Diagnosis and Management (2012, updated 2021); ICHD-3 classification (2021)

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