Useful link: exeterheadacheclinic.org.uk

Dr Giles Elrington of the National Migraine Centre demonstrates a 3 minute neurological examination to help exclude sinister causes of headache:



Useful link: nationalmigrainecentre.org.uk

Recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Aura present in around 30% of migraine attacks

Reconsider migraine diagnosis:

  • New onset headache in over 50s
  • Change in the pattern of long established migraine
  • Atypical aura symptoms
  • Monocular visual disturbance (consider amaurosis fugax or retinal detachment)
  • Red eye (consider angle closure glaucoma)
  • Double vision
  • Weakness
  • Poor balance


  • Encourage use of headache diary (paper diary from National Migraine Centre or Migraine Buddy app)
  • Manage co existent analgesic overuse if present
  • Do not scan for reassurance
  • Acute treatment
  • Combination of oral triptan + NSAID, or oral triptan+paracetamol
  • If first triptan fails, consider alternative preparation and route of administration
  • Alternatives include aspirin 900mg with or without antiemetic
  • Do not offer opioids
  • Prophylaxis
  • Consider propranolol or topiramate
  • Alternatives include amitriptyline, pizotifen, candesartan
  • Do not offer sodium valproate to females of childbearing potential
  • Riboflavin 400mg once daily may be effective (patient to source)
  • Discuss Botulinum Toxin for Chronic Migraine in the following
  • Headache on 15 days per month at least 8 of which are migrainous
  • Has had trials of at least three migraine preventatives
  • Is not overusing analgesics or triptans
  • Able to maintain diary


Cluster Headaches

With reference to gammacore.

Gammacore is a small portable device that can be used to treat severe pain in cluster and migraine headaches.  It is a small device which is held against the neck and delivers a low level electric current which improves the pain of cluster headaches.  It is a non-invasive vagus nerve stimulator.

NHSE is expanding the use of gamma core as a third line option for cluster headaches after successful trials held over the last two years.

Currently in Cornwall we are working with the neurology team and will hopefully be in a position to adopt the use of this as policy in Septmeber/October 2021.


Useful links:


Who to refer?

  • Uncertainty regarding diagnosis especially with atypical aura/focal symptoms
  • Failure to respond to standard acute and preventative therapies
  • Chronic migraine for consideration of botulinum toxin injection



Review Date                              13/05/2021

Next Review Date                      13/05/2022

Author                                      Dr Andrew Sharp / Dr Janine Glazier

Contributor                               Dr Jonathan Stewart Consultant Neurology RCHT


Version No.                   1.0