A stepped approach is often recommended commencing with an analgesic and antiemetic if required, and escalating to a 5HT1-receptor agonist (triptan) if this approach fails. All 5HT1- receptor agonists (triptans) are effective and well tolerated.
Migraine +/- aura, identification and avoidance of trigger factors.
- Sufferers may use non-drug therapies. Use of a 'trigger / attack diary' can help where attacks are frequent
- Drugs should be given as soon as the onset of an attack is recognised. Many patients respond to simple analgesics, these should be tried first
Simple oral analgesia +/- antiemetic
- Paracetamol 1g or
- Ibuprofen 400mg – 600mg or naproxen 500mg
- NSAIDs may be useful, but there is little evidence that one is any better than another. Soluble and rectal preparations are available (see section 10.1 Drugs used in rheumatic diseases and gout)
- Antimigraine preparations containing metoclopramide are not suitable for patients under the age of 20 years
Add prokinetic anti-emetic
- Domperidone tablets, liquid or suppositories or
- Metoclopramide tablets or syrup or
- Prochlorperazine suppository
- Aspirin and metoclopramide
- Paracetamol plus metoclopramide
- Paracetamol plus domperidone prescribed separately gives a reduced potential for extra-pyramidal side effects. Anti-emetics should ideally be given 30 minutes before analgesia
- Peristalsis is often reduced in migraine attacks. Soluble or dispersible drugs are preferred and should be given as soon as the onset of an attack is recognised
- The addition of a gastric motility agent will aid gastric emptying, as well as relieving nausea, and will increase the absorption of analgesics taken at the same time or slightly later.
- Opiates and opiate derivatives increase nausea and are addictive. Codeine and dihydrocodeine are associated with medication overuse headache and are therefore not recommended for the treatment of migraine
If severe vomiting problematic:
Rectal analgesic +/- Antiemetic (as above)
- Contraindications are peptic ulceration or lower bowel disease. Diarrhoea during acute migraine may prevent effective use.
Specific anti-migraine drugs
- 5HT1-receptor agonists, different triptans have different profiles of 5HT site action
- Sumatriptan should be tried first
- 5HT1 agonists should always be used as monotherapy and not concurrently with other acute migraine-specific therapies
- Should be taken as soon as possible after the onset of headache
- Headaches can recur within 24 hours in about 30-40% of patients treated with triptans
- Triptans are contraindicated in ischaemic heart disease, previous myocardial infarction and uncontrolled hypertension
- To treat an attack of migraine, only one dose of a triptan should be taken, not repeated if the first dose is ineffective
- If the headache recurs, a repeated oral dose may be necessary but taken at least 2 hours after the first dose. Subcutaneous sumatriptan can be repeated after one hour for a recurring headache.
- Review diagnosis
- Review compliance
- Consider combination treatment. There is no formal evidence for this but steps 1 + 3 may be worth trying, followed by steps 2+3
- Patients who overuse triptans may develop daily migraine like headaches or an increase in migraine frequency. It is useful to restrict the intake of triptans to a maximum of 10 single dosages per month. (Neurology 2002; 59:1011-1014).
- Where medication overuse headache is suspected referral to a hospital service / neurology department and/ or the Pain Clinic may be appropriate.
Another approach is stratified care in which the clinician grades each patient's migraine symptoms and selects a treatment that is likely to work.
Where migraine attacks are frequent, consideration should be given to the avoidance of trigger factors such as stress or diet (such as cheese, chocolate etc.).
Prophylaxis is used to reduce the number of acute attacks when acute therapy is inadequate.
Acute treatment for attacks will still be required as preventative therapy only reduces the frequency and severity of attacks but does not eliminate completely. It is likely that it will take between 1–3 months for the prophylactic medicine to take its full effect.
Prophylactic drugs that are effective should be continued for 4–6 months then withdrawn (tapered over 3-4 weeks) to establish continued need.
Prophylactic Management of Migraine
Beta blockers, see 2.4 Beta-adrenoceptor blocking drugs
- First-line choice for prophylaxis of migraine, unless contraindicated.
- Propranolol LA 80mg – 240mg daily in divided doses has the greatest evidence.
- Alternatives include atenolol (unlicensed) 50 – 200mg daily in divided doses or metoprolol 100 – 200mg daily in divided doses
- Contraindications include heart disease, asthma, depression and peripheral vascular disease.
Amitriptyline, see 4.3 Antidepressant drugs
- Initially 10mg at night, increased if necessary to maintenance of 50–75mg at night; maximum 150mg at night (unlicensed indication)
- To minimise side effects, treatment should be started at a low dose (10-25mg at night) and increased to a maintenance dose
Pizotifen, see 4.8 Antiepileptic drugs
- 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.
Sodium valproate and topiramate are recommended for second-line prophylaxis in adults.
Sodium valproate, see 4.8 Antiepileptic drugs
- Initially 200mg twice daily, increased if necessary to 1.2–1.5g daily in divided doses (unlicensed indication)
Topiramate, see 4.8 Antiepileptic drugs
- Starting dose 25mg alternate days increasing in 25mg increments every 2 weeks till initial maintenance of 50mg twice daily (licensed for specialist initiation).
- In practice can be effective but sometimes tolerability (cognitive side effects and low mood) can be an issue. Beware of risk of kidney stones and glaucoma (both rare)
Women should not get pregnant whilst taking the antiepileptic class of migraine prophylaxis, and should take 5mg folic acid in case of contraceptive failure (thought to minimise teratogenic effects). Issues regarding antiepileptic treatments and contraception, pregnancy/teratogenicity are more fully outlined in the epilepsy section (see 4.8 Antiepileptic drugs).