For acute episodic TTH, NICE recommends paracetamol, aspirin or an NSAID such as ibuprofen or naproxen, but to avoid opiates and triptans. For chronic TTH, it may be necessary to exclude a diagnosis of migraine, medication over-use headache or depression and try to identify possible triggers. Consider preventive treatment if pain relief is needed on two or more days each week; NICE recommends acupuncture or possibly amitriptyline.12

Cluster headaches rarely respond to standard analgesics, says the BNF. Instead, first line treatments are:13

·      subcutaneous sumatriptan

·      nasal sprays containing sumatriptan or zolmitriptan, or

·      100% oxygen.

The cluster headache charity OUCH UK warns that GPs may want to prescribe oral sumatriptan as it is cheaper than injections, “but the tablets simply are not strong enough to deal with the pain of CH and can take up to 30 minutes to start working.”5

Prophylaxis for cluster headache includes off-label prescribing of verapamil, lithium or prednisolone, while ergotamine may be suitable for limited, short bouts.13 Advise patients to ensure that any GP referral to a neurologist is to one specialising in headache disorders.5