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NICE CG150: Headaches in over 12s: diagnosis and management (updated November 2015). Advice on the diagnosis and management of headache and migraine.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is infrequent migraine.
Many migraine treatments e.g. analgesia, anti-sickness medicines, and sumatriptan are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
A headache diary for a minimum of eight weeks from the patient can help with decisions about on-going treatment.
Offer combination therapy with:
Or
For patients who prefer to take only one drug consider monotherapy with:
Consider adding an anti-emetic even in the absence of nausea and vomiting to promote gastric emptying and peristalsis:
Notes:
Always consider the possibility of medication overuse in patients with chronic headache.
If medication overuse headache is suspected, all overused acute headache treatment should be stopped for at least 1 month. ideally wait for 1 to 2 months following withdrawal of overused medication, and then assess the need for further management of the underlying headache disorder, and whether prophylaxis is required. Seek advice form a neurology or Pain clinic.
Prophylaxis is used to reduce the number of acute attacks when acute therapy is inadequate. Acute treatment will still be required as preventative therapy does not eliminate attacks completely.
In general, consider prophylaxis where the:
Prophylactic drugs that are apparently not effective should not be discontinued too soon, since efficacy may be slow to develop, particularly when dose titration is necessary. In the absence of unacceptable side-effects, 8-10 weeks is a reasonable trial following dose titration.
Review the need for continuing migraine prophylaxis six months after the start of prophylactic treatment. Withdrawal should be considered to establish continued need. Withdrawal is best achieved by tapering the dose over 2-3 months. Migraine is cyclical and treatment is required for periods of exacerbation. Uninterrupted prophylaxis over very long periods is rarely appropriate.
First line options
Offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:
Follow the MHRA safety advice on topiramate
Second line option
Notes:
Migraine during pregnancy is quite unusual, with 60% -70% of women experiencing an improvement in symptoms. In general, drug treatment should be limited during pregnancy. If treatment is essential, it should be prescribed at the lowest effective dose for the shortest possible time and a discussion of the risks and benefits documented.
Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.