In general, the recommendations in all guidelines are very similar both for acute and for prophylactic drug treatment. All guidelines recommend the use of NSAIDs and of triptans in acute migraine treatment. Ergotamine derivatives are not drugs of first choice any more in the guidelines after the year 2010. For the prophylactic drug treatment, beta-blockers and anticonvulsant drugs (valproic acid and topiramate) are first choice in all guidelines. There is a considerable difference in some countries with respect to antidepressants in migraine prophylactic treatment. This has also been noticed in previous comparisons of migraine guidelines [1], and this is also a major difference to the US American guideline on migraine prevention [25].

Systematic comparisons for the treatment of other headache disorders cannot be made since in many countries only migraine guidelines exist. For tension-type headache and for cluster headache, the available evidence on drug treatment is poor and only very few trials exist. Therefore, evidence-based treatment guidelines are difficult to create. For other primary headache disorders, only one guideline could be identified [6]; the available evidence for drug treatment in this group is even poorer. There are no guidelines on the treatment of secondary headaches and only a few on the treatment of trigeminal neuralgia and facial pain.

With respect to cross-sectional guidelines, only children and adolescents have been addressed in more than one guideline. Often, all age groups were included in one guideline but discussed separately in different chapters. Since specific trials on different patient groups in headache treatment are rare, good evidence is hard to obtain for cross-sectional guidelines.

According to a previous analysis of guidelines [1], guidelines are developed to assist the physician in making appropriate choices in the treatment of headache patients. To ensure their optimal use, guidelines need to be kept up to date; they should encompass the most recent published evidence and therapeutic strategies. Because guidelines are needed to set recognizable and acceptable standards of good practice, their adoption in primary care should be encouraged. This has, however, not been the case in most guidelines published in Europe.