A headache diary for a minimum of eight weeks from the patient can help with decisions about on-going treatment.

Offer combination therapy with:

• Oral sumatriptan and an NSAID (see section 4.7.4 Antimigraine drugs and section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs))

Or

• Oral sumatriptan and paracetamol (see section 4.7.4 Antimigraine drugs and section 4.7.1 Non-opioid analgesics and compound analgesic preparations)

For patients who prefer to take only one drug consider monotherapy with:

• Oral sumatriptan (see section 4.7.4 Antimigraine drugs) or,
• An NSAID (see section 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)) or,
• Aspirin (900mg dose) (not for children under 16 years of age) (see section 2.9 Antiplatelet drugs) or,
• Paracetamol (see section 4.7.1 Non-opioid analgesics and compound analgesic preparations)

Consider adding an anti-emetic even in the absence of nausea and vomiting to promote gastric emptying and peristalsis:

• Metoclopramide (see section 4.6 Drugs used in nausea and vertigo)
• Prochlorperazine (see section 4.6 Drugs used in nausea and vertigo)
• Domperidone (see section 4.6 Drugs used in nausea and vertigo)

Notes:

5HT1 agonists (triptans)

1. When prescribing a triptan, start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans
2. Should be taken as soon as possible after the onset of headache
3. Triptans are associated with return of symptoms within 48 hours in 20-50% of patients who have initially responded
4. Triptans are contraindicated in patients with the following conditions: ischaemic heart disease, previous myocardial infarction, coronary vasospasm, symptoms or signs consistent with ischaemic heart disease, peripheral vascular disease, cerebrovascular accident, transient ischaemic attack, moderate and severe hypertension, and mild uncontrolled hypertension
5. To treat an attack of migraine, only one dose of a triptan should be taken, not repeated if the first dose is ineffective
6. If the headache recurs, a repeated oral dose may be necessary but taken at least two hours after the first dose. Subcutaneous sumatriptan can be repeated after one hour for a recurring headache
7. Patients who overuse triptans may develop daily migraine-like headaches or an increase in migraine frequency. See "Medication Overuse Headache" below for guidance

Ergots or opioids

1. Do not offer ergot or opioids for the acute treatment of migraine. Opiates and opiate derivatives increase nausea and are addictive. Codeine and dihydrocodeine are associated with medication overuse headache.

Medication Overuse Headache

1. Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:
   1. Triptans, opioids, ergots or combination analgesic medications on 10 days per month or,
   2. Paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days or more per month
2. 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 from a neurology department or Pain clinic.

Anti-emetic

1. Please refer to the MHRA Drug Safety Updates for domperidone and for metoclopramide which can be found in section 4.6 Drugs used in nausea and vertigo.

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:

• Patient suffers three moderate to severe headache days a month when acute medications are not reliably effective
• The patient has greater than eight headache days a month even when acute medications are optimally effective because of the risk of medication overuse headache

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.

Treatment pathway

First line options

• Offer propranolol (see section 2.4 Beta-adrenoreceptor blocking drugs) or,
• Topiramate (see section 4.8.1 Control of the epilepsies)

Topiramate: new safety measures including a pregnancy prevention programme (MHRA Drug Safety Update, June 2024)

NICE CG150: NICE is reviewing its guidance.

Offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:

• the potential benefit in reducing migraine recurrence and severity
• the risk of foetal malformations with topiramate (see topiramate, note 1 below)
• the risk of reduced effectiveness of hormonal contraceptives with topiramate
• the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (see topiramate, note 1 below)

Second line option

• Offer amitriptyline (see section 4.3.1 Tricyclics and related anti-depressants)

Further options

Rimegepant

1. Oral lyophilisate.
2. 75mg once daily on alternate days.
3. Rimegepant should be started by a headache specialist. Prescribing is to remain with the specialist team until treatment is reviewed in line with NICE TA906. If following a review at 12 weeks, rimegepant is found to be effective, a GP may be asked to continue prescribing.
4. In line with TA906 as an option for preventing episodic migraine in adults who have at least 4 and fewer than 15 migraine attacks per month, only if at least 3 preventative treatments have not worked.
5. See section 4.7.4 Antimigraine drugs

Refer also to section 4.7.4 Antimigraine drugs and section 4.9.3 for botulinum toxin

Notes:

Propranolol

1. 80mg-240mg daily in divided doses
2. Contraindications include heart disease, asthma, chronic obstructive pulmonary disease, and peripheral vascular disease

Topiramate

1. MHRA Drug Safety Update (June 2024): Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme
   1. Refer to the safety update for further information
   2. The safety update includes advice for health professionals to provide to patients
2. Licensed for migraine prophylaxis. Starting dose is 25mg at night for one week followed by weekly increases of 25mg/day. If the patient is unable to tolerate the titration, longer intervals between dose adjustments can be used. Usual dose 50mg-100mg/day in two divided doses
3. Topiramate is associated with decreased appetite. Patients should be monitored for weight loss.
4. Adequate hydration is advised to reduce the risk for renal stone formation.
5. For CSM warning on secondary angle glaucoma (see section 4.8.1 Control of the epilepsies).

Amitriptyline

1. To minimise side effects, treatment should be started at a low dose (10mg at night) and increased to40mg-50mg at night. Local specialist advice is that tolerability is reduced at higher doses and a maximum dose of 100mg at night is recommended

Other drugs

1. The use of sodium valproate, pizotifen and gabapentin for migraine prophylaxis has been superseded
2. NICE CG150 recommends that for people who are already having treatment with another form of prophylaxis and whose migraine is well controlled, continue the current treatment as required, however for patients receiving sodium valproate, refer to the Drug Safety Update below for new safety measures including a pregnancy prevention programme.
   1. MHRA Drug Safety Update (January 2024): Valproate (Belvo, Convulex, Depakote, Dyzantil, Epilim, Epilim Chrono or Chronosphere, Episenta, Epival, and Syonell▼): new safety and educational materials to support regulatory measures in men and women under 55 years of age

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.