Adult with headache
New or recurrent headache in an adult. Not for children or adolescents.
All Pathways
Family MedicineDiagnostic
Adult Headache Evaluation & Management (Primary Care)
Adult Headache Evaluation & Management (Primary Care): Adult with headache → Any red flag? → Red flag present: urgent assessment.
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Decision Any red flag?
Sudden severe onset, seizure or collapse, fever, neck stiffness or rash, new neurological deficit, new headache at 50 or over, pregnancy or postpartum, cancer, immunosuppression, head injury or anticoagulant, cough- or posture-triggered, progressive, painful red eye, possible carbon monoxide. Yes: urgent assessment.
- Sudden severe headache peaking within 1 hour (thunderclap: peak within 1 min)
- Fever, neck stiffness or rash; or immunosuppression (HIV, immunosuppressive drugs)
- New neurological deficit, confusion, personality change, reduced consciousness or papilloedema
- Seizure, faint or collapse at onset
- Age 50 or over with new headache, or jaw claudication, scalp tenderness or visual symptoms (giant cell arteritis)
- Pregnant or postpartum
- History of cancer that can spread to the brain
- Triggered by cough, Valsalva, sneeze or exercise; or changes with posture
- Head injury in the past 3 months, or on an anticoagulant
- Painful red eye with halos (acute angle-closure glaucoma)
- Progressive headache, vomiting with no other cause, or a marked change in pattern
- Others in the home with headache (carbon monoxide)
- If Yes
03Action Red flag present: urgent assessment
Suspected meningitis or giant cell arteritis: treat first. Do not wait for CT or LP. Other red flags: emergency or urgent assessment by cause (see list).
- Suspected meningococcal disease (for example non-blanching rash): give ceftriaxone 2 g (adult) IV or IM now, or benzylpenicillin 1.2 g IV or IM, unless this delays transfer. Other suspected bacterial meningitis: emergency transfer; give the antibiotic first if transfer will be delayed. Severe allergy to penicillin or cephalosporin: no antibiotic before hospital.
- Suspected giant cell arteritis: start prednisolone 40-60 mg daily (adult) the same day; ESR and CRP; same-day specialist referral. Visual loss: emergency.
- Sudden severe onset, seizure, collapse or acute neurological deficit: emergency department now. Non-contrast CT brain; if CT is normal and subarachnoid haemorrhage is still suspected, LP or CT angiography.
- Pregnant or postpartum: check BP and urine protein (pre-eclampsia); consider venous sinus thrombosis and RCVS; urgent review.
- Head injury or anticoagulant: urgent CT brain.
- Suspected tumour, abscess or venous sinus thrombosis: urgent MRI (with MR venography) or CT.
- Painful red eye with halos: same-day ophthalmology.
- Suspected carbon monoxide: remove from the source, give high-flow oxygen, emergency department for carboxyhaemoglobin.
- If serious causes are excluded: follow the primary headache steps.
If No04Warning No red flag: check medication overuse first
Medication overuse headache: headache on 15 or more days/month with regular overuse for more than 3 months.
- Overuse: triptans, opioids, ergots or combination analgesics on 10+ days/month; or paracetamol, aspirin or NSAIDs on 15+ days/month
- Treat: stop overused medicines abruptly for at least 1 month (strong opioids: specialist advice); headache may worsen at first
- Consider prevention for the underlying headache; review 4-8 weeks after withdrawal
05Decision Primary headache type?
Classify by ICHD-3 features. A headache diary helps. None fits: reassess and refer.
- Migraine: 4-72 h; 2 of unilateral, pulsating, moderate-severe, worse with activity; plus nausea, or light and sound sensitivity
- Tension-type: bilateral, pressing, mild-moderate, not worse with activity; no nausea
- Cluster: severe one-sided orbital or temporal pain, 15-180 min, same-side tearing, red eye, nasal symptoms or restlessness
- Migraine features
06Action Migraine features: confirm migraine
Episodic, or chronic if headache on 15+ days/month for more than 3 months (migraine features on 8+ days). Atypical aura (motor weakness, double vision, visual symptoms in one eye only, poor balance or reduced consciousness): investigate or refer; no triptan until assessed.
- ICHD-3: at least 5 attacks of 4-72 h with 2 of: unilateral, pulsating, moderate-severe, worse with routine activity
- Plus 1 of: nausea or vomiting; or both photophobia and phonophobia
- Aura: fully reversible visual, sensory or speech symptoms, each lasting 5-60 min
- Migraine with aura: do not use combined hormonal contraception
- Headache diary: frequency and acute medicine days
07Warning Before acute treatment: triptan and NSAID contraindications
If any apply, do not use that drug class. Choose another option. Atypical aura not yet assessed (possible TIA or stroke): no triptan. Over 65: sumatriptan not recommended. With an SSRI or SNRI: watch for serotonin syndrome.
- Triptan: not with ischaemic heart disease, prior MI, coronary vasospasm, stroke or TIA, peripheral vascular disease, uncontrolled hypertension
- Triptan: not with hemiplegic or brainstem aura, MAOI within 2 weeks, ergot within 24 h, severe liver impairment. With propranolol: do not use rizatriptan 10 mg; choose another triptan
- NSAID: not with aspirin- or NSAID-induced asthma, peptic ulcer or GI bleeding, severe kidney disease, heart failure, anticoagulants, or pregnancy from 20 weeks
08Action Migraine acute treatment
Treat early in the attack. Keep triptans and combination analgesics under 10 days/month, simple analgesics under 15 days/month. Pregnancy: paracetamol first.
- Simple: aspirin 900 mg, paracetamol 1 g, ibuprofen 400 mg, or naproxen 750 mg (then 250-500 mg after 1 h if needed; max 1250 mg/day)
- Triptan: sumatriptan 50-100 mg orally (max 300 mg/24 h) or 6 mg SC (max 12 mg/24 h); rizatriptan 10 mg (max 30 mg/24 h)
- One drug not enough: triptan plus NSAID, or triptan plus paracetamol
- Add an antiemetic, even without nausea: metoclopramide (age 20 or over) or prochlorperazine. Parkinson's disease: avoid both
- 2 triptans fail, or triptans unsuitable and NSAIDs and paracetamol fail: rimegepant 75 mg orally disintegrating tablet (max 75 mg/24 h; not with strong CYP3A4 inhibitors, or strong or moderate CYP3A4 inducers)
- Do not use opioids or ergots
- Pregnancy: paracetamol first; triptan or NSAID only after discussing risks
09Decision Prevention needed?
Consider if attacks disable despite good acute treatment, or are frequent, or acute medicines are overused or unsuitable.
- Frequent attacks (for example 4 or more migraine days/month)
- Disability despite good acute treatment
- Acute medicines contraindicated, not tolerated or not working
- Medication overuse
- If Yes
10Warning Prevention needed: check pregnancy and contraception first
Pregnant or planning pregnancy: seek specialist advice before any preventive.
- Topiramate: contraindicated in pregnancy; women who could become pregnant need highly effective contraception. It can reduce hormonal contraceptive effect: add a barrier method
- Valproate: do not use in women or girls who could become pregnant (not TGA-approved for migraine)
- Propranolol and amitriptyline are dangerous in overdose: ask about depression and self-harm
11Action Migraine prevention: choose by comorbidity
Trial each for at least 8 weeks at target dose. Propranolol: not with asthma, bradycardia, heart block or heart failure. Amitriptyline: caution in conduction disease and older adults.
- Propranolol 40 mg twice daily; usual 80-160 mg/day
- Topiramate 25 mg at night; increase by 25 mg/day each week to 50 mg twice daily
- Amitriptyline (off-label): start 10 mg at night; increase slowly
- Other options: candesartan (off-label), pizotifen
- CGRP antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) or gepants (atogepant, rimegepant): AHS 2024 supports first-line use. PBS subsidy (listed antibodies) needs 3 oral preventives failed, not tolerated or contraindicated
- Chronic migraine: onabotulinumtoxinA via specialist
- Review need for prevention at 3-6 months
12Action Refer to neurology if needed
Diagnostic doubt, 2 or more preventives failed, chronic migraine, cluster headache, or overuse not settling.
- Diagnostic uncertainty or atypical features
- Two or more preventives failed or not tolerated
- Chronic migraine (onabotulinumtoxinA or CGRP therapy)
- Cluster headache or other trigeminal autonomic cephalalgia
- Medication overuse with strong opioids, or failed withdrawal
- Prevention needed in pregnancy
If No13Outcome No prevention now: continue acute plan
Keep a headache diary. Review if attacks become more frequent or acute medicine days rise.
- Tension features
14Action Tension-type features
Most common primary headache. Episodic, or chronic if on 15+ days/month.
- Bilateral, pressing or tightening, mild to moderate
- Not worse with routine physical activity
- No nausea or vomiting; at most one of photophobia or phonophobia
- Lasts 30 min to 7 days
15Action Tension-type treatment
Acute: aspirin, paracetamol or an NSAID (see NSAID contraindications). Do not use opioids.
- NSAID: not with aspirin- or NSAID-induced asthma, peptic ulcer or GI bleeding, severe kidney disease, heart failure, anticoagulants, or pregnancy from 20 weeks
- Keep simple analgesics under 15 days/month
- Chronic tension-type: consider amitriptyline (off-label, start 10 mg at night; not soon after MI; caution in conduction disease, older adults, depression or self-harm risk) or up to 10 sessions of acupuncture over 5-8 weeks
- Address sleep, stress and posture; consider physiotherapy
- Path rejoins step 12Shared downstream outcome
- Cluster features
16Action Cluster headache: oxygen or injected triptan
No triptan with vascular disease, uncontrolled hypertension or MAOI use. Over 65: sumatriptan not recommended. With an SSRI or SNRI: watch for serotonin syndrome. Refer to neurology to confirm and start prevention.
- Severe one-sided orbital or temporal pain, 15-180 min, up to 8 a day; same-side tearing, red eye, nasal symptoms, ptosis or restlessness
- Acute: 100% oxygen at 12 L/min or more by non-rebreather mask with reservoir; arrange home oxygen
- COPD with CO2 retention: seek respiratory advice before home high-flow oxygen. No smoking near oxygen
- Acute: sumatriptan 6 mg SC (max 12 mg/24 h), or sumatriptan 20 mg nasal spray (off-label; max 40 mg/24 h)
- Do not use paracetamol, NSAIDs, opioids, ergots or oral triptans
- Prevention: verapamil with specialist advice and ECG monitoring
- First bout: discuss neuroimaging with neurology
- Path rejoins step 12Shared downstream outcome
- None fits
17Action Fits no primary type: reassess, then refer
Look again for a secondary cause and for medication overuse. Refer to neurology if the type stays unclear.
- Recheck red flags; examine neurology and fundi
- Consider other primary headaches (for example trigeminal neuralgia, hemicrania) and secondary causes (for example medicines, sleep apnoea)
- Headache diary for at least 8 weeks
- Path rejoins step 12Shared downstream outcome
Guideline Source
NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only: children and adolescents need a paediatric headache pathway.
- Pregnancy and postpartum: treat headache as a red flag; acute and preventive choices need obstetric or specialist advice.
- CGRP-targeting drugs: specific agents and full PBS and NICE criteria are not detailed.
- Cluster headache prevention and other trigeminal autonomic cephalalgias need specialist care.
- Red-flag list supports, and does not replace, clinical judgement and local imaging pathways.
Contraindicated Populations
Children and adolescents under 18 years
Applicable Regions
USAUUKEU
AU: Therapeutic Guidelines: Neurology is the local reference. Ubrogepant and dihydroergotamine are not on the ARTG. Rimegepant 75 mg ODT, pizotifen and sumatriptan 6 mg injection are registered. Valproate and amitriptyline are not TGA-approved for migraine. PBS criteria apply to CGRP antibodies.
UK: NICE CG150 (updated 2025) and NICE technology appraisals for CGRP-targeting drugs and botulinum toxin.
US: AHS 2021 consensus statement (acute and preventive treatment) and AHS 2024 position statement on CGRP-targeting therapies.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Adult Headache Evaluation & Management (Primary Care)?
The Adult Headache Evaluation & Management (Primary Care) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025).
What guideline is the Adult Headache Evaluation & Management (Primary Care) based on?
This algorithm is based on NICE CG150 Headaches in over 12s: diagnosis and management (last updated June 2025).
What are the limitations of the Adult Headache Evaluation & Management (Primary Care)?
Known limitations include: Adults only: children and adolescents need a paediatric headache pathway.; Pregnancy and postpartum: treat headache as a red flag; acute and preventive choices need obstetric or specialist advice.; CGRP-targeting drugs: specific agents and full PBS and NICE criteria are not detailed.; Cluster headache prevention and other trigeminal autonomic cephalalgias need specialist care.; Red-flag list supports, and does not replace, clinical judgement and local imaging pathways.. Individual patient factors may require deviation from these recommendations.
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