4.7.4 Antimigraine drugs

5HT1-receptor agonists

Sumatriptan
  • Tablet 50mg, 100mg (£0.24 = per tablet 100mg)
  • Injection 6mg/0.5ml syringe (£45.00 = pack 2 generic pre-filled syringes)
  • Injection 3mg/0.5ml syringe (£39.50 = pack 2 pre-filled syringes) (see note 2 below)
  • Nasal spray 10mg/0.1ml actuation, 20mg/0.1ml actuation (£42.47 = 20mg pack 6 unit doses)

Indications

Dose

  • Oral: migraine. Dose: 50mg (some patients may require 100mg); the dose may be repeated after at least 2 hours if migraine recurs; maximum 300mg in 24 hours
  • Subcutaneous 6mg injection: cluster headache or migraine. Dose: a single 6mg injection; the dose may be repeated once after at least 1 hour if headache recurs; maximum 12mg in 24 hours
  • Subcutaneous 3mg injection: migraine if sumatriptan 6mg injection is effective, but not tolerated. Dose: a single 3mg injection; the dose may be repeated once after at least 1 hour if headache recurs; maximum 6mg in 24 hours (see note 2 below)
    • Intranasally: cluster headache (unlicensed) or migraine. Dose: 10–20mg into one nostril; the dose may be repeated once after at least 2 hours if headache recurs. Maximum in 24 hours: two 10mg doses or two 20mg doses.
    Notes
    1. Sumatriptan nasal spray is licensed for use in children aged 12 to 18 years of age
    2. Sumatriptan 3mg subcutaneous injection is included in the formulary for the treatment of migraine only. There is very limited evidence comparing sumatriptan 3mg and 6mg subcutaneous injection. If sumatriptan 6mg subcutaneous injection is effective but not tolerated, consider reducing the dose to the 3mg injection. If a patient consistently uses more doses of sumatriptan 3mg injection than the 6mg injection, prescribing of the 3mg injection should be reconsidered.
    3. All prescriptions for sumatriptan should be written generically.
    Rizatriptan
    • Tablet 5mg, 10mg (£2.75 = per tablet 10mg)
    • Orodispersible tablets 10mg (£5.09 = per tablet)

    Indications

    Dose

    • 10mg as soon as possible after onset repeated after 2 hours if migraine recurs (patient not responding should not take second dose for same attack); maximum 20mg in 24 hours

    Notes

    1. Orodispersible or wafer formulations obviate the need for water but do not get absorbed in the mouth.
    2. The plasma concentration of rizatriptan is increased by propranolol. For patients taking propranolol the maximum dose of rizatriptan is 5mg
    Frovatriptan
    • Tablet 2.5mg (£1.41 = per tablet)

    Indications

    Dose

    • 2.5mg as soon as possible after onset repeated after 2 hours if migraine recurs (patient not responding should not take second dose for same attack); maximum 5mg in 24 hours

    Notes

    1. Frovatriptan has a long elimination half-life and may be of benefit for patients who experience recurrence of headache.

    Prophylaxis of migraine

    Drugs used for prophylaxis of migraine not listed below:

    Pizotifen
    • Tablet 500 microgram, 1.5mg (£1.31 = 1.5mg x 28 tablets)

    Indications

    • Prevention of vascular headache including classical migraine, common migraine, and cluster headache

    Dose

    • Initially 500 micrograms at night increased gradually to usual dose of 1.5mg at night or in 3 divided doses; may be further increased up to maximum daily dose 4.5mg (but rarely necessary), maximum single dose 3mg

    Notes

    1. The evidence for the use of pizotifen is limited and weight gain and sedation are often unacceptable side effects of this drug, it has now been superseded.
    Erenumab
    • Solution for injection pre-filled pens 70mg/1ml, 140mg/1ml

    Notes

    1. NICE TA682: Erenumab (Aimovig) is recommended as an option for preventing migraine in adults (March 2021), only if:
      1. they have 4 or more migraine days a month
      2. at least 3 preventive drug treatments have failed
      3. the 140mg dose of erenumab is used and
      4. the company provides it according to the commercial arrangement
    2. Stop erenumab after 12 weeks of treatment if:
      1. in episodic migraine (less than 15 headache days a month) the frequency does not reduce by at least 50%
      2. in chronic migraine (15 headache days a month or more with at least 8 of those having features of migraine) the frequency does not reduce by at least 30%
    3. The preferred option in Devon for the treatment of patients with chronic migraine who have failed on at least 3 preventative drug treatments is Botulinum Toxin Type A (Botox®) (see 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders)
    Fremanezumab
    • Solution for injection pre-filled pens 225mg in 1.5ml

    Notes

    1. NICE TA631: Fremanezumab (Ajovy) is recommended as an option for preventing migraine in adults (June 2020), only if:
      1. the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least 8 of those having features of migraine
      2. at least 3 preventive drug treatments have failed and
      3. the company provides it according to the commercial arrangement
    2. Stop fremanezumab if the migraine frequency does not reduce by at least 30% after 12 weeks of treatment
    3. The preferred option in Devon for the treatment of patients with chronic migraine who have failed on at least 3 preventative drug treatments is Botulinum Toxin Type A (Botox®) (see 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders)
    Galcanezumab
    • Solution for injection pre-filled pens 120mg/1ml

    Notes

    1. NICE TA659: Galcanezumab (Emgality) is recommended as an option for preventing migraine in adults (November 2020), only if:
      1. they have 4 or more migraine days a month
      2. at least 3 preventive drug treatments have failed and
      3. the company provides it according to the commercial arrangement
    2. Stop galcanezumab after 12 weeks of treatment if:
      1. in episodic migraine (less than 15 headache days a month) the frequency does not reduce by at least 50%
      2. in chronic migraine (15 headache days a month or more with at least 8 of those having features of migraine) the frequency does not reduce by at least 30%
    3. The preferred option in Devon for the treatment of patients with chronic migraine who have failed on at least 3 preventative drug treatments is Botulinum Toxin Type A (Botox®) (see 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders)

    Non-steroidal anti-inflammatory drugs

    Aspirin and metoclopramide
    • Oral powder, aspirin 900mg plus metoclopramide 10mg (£6.61 = 6 sachets)

    Indications

    • Acute migraine

    Dose

    • One sachet in water at onset of attack, repeated after 2 hours if necessary (maximum 3 sachets in 24 hours)

    Notes

    1. Antimigraine preparations containing metoclopramide are not suitable for patients under the age of 20 years.

    Other preparations

    Dihydergotamine
    • Injection 1mg/1ml (unlicensed preparation)
    Flunarizine
    • Capsules 5mg (unlicensed preparation)
    Methysergide
    • Tablets 1mg (unlicensed preparation)

     

    Home > Formulary > Chapters > 4. Central Nervous System > 4.7 Analgesics > 4.7.4 Antimigraine drugs

     

    • First line
    • Second line
    • Specialist
    • Hospital