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Headache guidance? NICE try

Ha ha ha ha ha ha ha ha. Brilliant. Say what you like about NICE – and I do, often, it’s a constant source of inspiration for these blogs – but it certainly has a sense of humour.

I say this because of its hot-off-the-press guidance on headache - though to really appreciate NICE’s comic genius, I first need to remind you about its other recent guideline, on osteoporosis.

Essentially, this suggested we should screen for osteoporosis everyone and his dog, and probably the dog’s bone, too. This was met with such utter incredulity that the NICE wallahs are concerned we GPs might just start to ignore its pronouncements. Solution? Produce some guidance so surprising, so at odds with what goes on in the real world, so different to other existing guidelines and so darn weird and wacky that we all sit up and take notice. Then NICE can say, ‘Ha, caught you out’, and, having grabbed our attention, slip the real headache guidelines under our by now twitching noses.

So, ladies and gentlemen, prepare to have your ribs tickled. Because here are the top lines of NICE’s spoof headache guidance:

  1. The first line treatment for acute migraine is now a triptan and paracetamol or an NSAID.
  2. Amitriptyline does not have an adequate evidence base to be recommended for chronic tension headache or migraine prevention.
  3. Acupuncture, though, does.
  4. There is evidence that riboflavin helps recurrent migraine.

Oh, ease my aching sides. Let’s just run through that again. I kick off with polypharmacy, I bin primary care’s favourite drug, amitriptyline, I embrace the idea that sticking needles in people isn’t good just for extracting blood, CSF or money and I ignore the fact that even if I can overcome this conceptual hurdle, acupuncture isn’t widely available anyway, and, oh yeah, if all else fails migraine-wise, try giving the patient some vitamins.

Brilliant. Though, now I’ve stopped laughing, and I’m waiting for the real guidance, I appear to be developing some sort of headache. And I have no idea how to treat it.

Dr Tony Copperfield is a GP in Essex. You can email him at and follow him on Twitter @DocCopperfield