As a memory aid we have identified the following 'Ten Commandments' of headache management. These do not aim to be comprehensive, but try to provide some essential 'do's and don'ts' that will help the healthcare professional to diagnose and manage migraine efficiently.

Screening/Diagnosis

1. Almost all headaches are benign and should be managed in general practice*.

2. Use questions/a questionnaire assessing impact on daily living for diagnostic screening and to aid management decisions. (Any episodic, high impact headache should be given a default diagnosis of migraine.)

Management

3. Share migraine management between the doctor and patient. (The patient taking control of their management and the doctor providing education and guidance.)

4. Provide individualised care for migraine and encourage patients to treat themselves. (Migraine attacks are highly variable in frequency, duration, symptomatology and impact.)

5. Follow-up patients, preferably with migraine diaries. (Invite the patient to return for further management and apply a proactive policy.)

6. Adapt migraine management to changes that occur in the illness and its presentation over the years. (For example, migraine may change to chronic daily headache over time.)

Treatments

7. Provide acute medication to all migraine patients and recommend it is taken as early as possible in the attack. (Triptans are the most effective acute medications for migraine. Avoid the use of drugs that may cause analgesic-dependent headache, e.g. regular analgesics, codeine and ergotamine.)

8. Prescribe prophylactic medications to patients who have four or more migraine attacks per month or who are resistant to acute medications. (First-line prophylactic medications are beta-blockers, sodium valproate^{�?/SUP> and amitriptyline�?/SUP>.)}

9. Monitor prophylactic therapy regularly.

10. Ensure that the patient is comfortable with the treatment recommended and that it is practical for their lifestyle and headache presentation.

*Points indicating sinister headaches requiring referral include new-onset, acute headaches associated with a range of other symptoms (e.g. rash, neurological deficit, vomiting and pain or tenderness, accident or head injury, infection or hypertension) and neurological change/deficit does not disappear when the patient is pain-free between headache attacks. A full neurological examination is essential if sinister headache is suspected.
^{�?/SUP>,�?/SUP>Not licensed for migraine prophylaxis in the UK.}

These new guidelines would not have been possible without the input and endorsement from the physicians, nurses, chiropractor and representatives of patient groups who attended the two MIPCA meetings on 24 May and 9 August 2002. We wish to thank all the delegates at the meetings: Chairman: Dr Andrew Dowson; GPs: Dr Anthony Bland, Dr Douglas Bremner, Dr Frances Carter, Dr Stan Darling, Dr Heather Fearon, Dr Bill Laughey, Dr Sue Lipscombe, Dr Trevor Rees, Dr Jerry Sender, Dr David Watson; Chiropractor: Dr Gregory Parkin-Smith; Nurses: Ms Jan Dungay, Ms Heather McBean; Patients' group (Migraine Action Association): Ms Ann Turner, Ms Anita Few. We also thank the numerous physicians who reviewed the draft manuscript of this article and provided valuable input. The two meetings were sponsored by unrestricted educational grants from Allergan, GlaxoSmithKline, The Migraine Action Association and York Nutritional Laboratories. Dr Pete Blakeborough of Alpha-Plus Medical Communications Ltd provided consultancy and assistance with the drafting of the guidelines.

Address for correspondence: Dr Andrew J. Dowson, The King's Headache Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK

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