Management of migraine

NICE CG150: Headaches in over 12s: diagnosis and management (updated November 2015)

Advice on the diagnosis and management of headache and migraine.

Treatment of acute migraine

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:

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 sympotms 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.

Prophylaxis of migraine

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.

First line options

Second line option

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. Initially 25mg once daily for one week, dose to be taken at night, then increased in steps of 25mg every week; usual dose 50mg-100mg daily in two divided doses; maximum 200mg per day
  2. Women and girls of childbearing potential must be informed that topiramate is associated with a risk of foetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception. Topiramate use for migraine prophylaxis is contraindicated in pregnancy and in women of child-bearing potential if not using an effective method of contraception
  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 to 40mg-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 superceded
  2. Botulinum toxin type A is recommended as an option for prophylaxis of migraine in accordance with NICE TA260 (June 2012) (see section 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders)
  3. For people who are already having treatment with another form of prophylaxis and whose migraine is well controlled, continue the current treatment as required

Migraine during pregnancy

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.

 

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