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 analgesics)

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) (see section 2.9 Antiplatelet drugs) or,
• Paracetamol (see section 4.7.1 Non-opioid analgesics and compound analgesics)

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. Patients have variable responses to triptans. Patients with a poor response to one triptan may benefit from another triptan in subsequent attacks.
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.
8. Orodispersible and "Melt" formulations of triptans are not included in the formulary, they offer no clinical advantage and are for convenience only. These formulations of triptans are gastrically absorbed. In patients who vomit early, consider a nasal or subcutaneous triptan. A significant proportion of the nasal dose is still gastrically absorbed.

Ergots or opioids

1. Do not offer ergot or opioids for the acute treatment of migraine. Opioids and opioid 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 more, or
   2. Paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more

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, then assess the need for further management of the underlying headache disorder and whether prophylaxis is required. Occasionally for a person who is unable to otherwise withdraw from the overused medication, prophylactic treatment may be considered in addition to withdrawal.

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.

The decision to initiate prophylaxis should be made in conjunction with the patient taking into account the number of attacks per month and the impact of these on the patient's life.

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

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 6 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 2 and 6 below)

Follow the MHRA safety advice on topiramate

Second line option

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

Notes

Propranolol

1. Licensed for migraine prophylaxis. Start at a low dose and attempt to titrate up to 160mg SR daily.
2. Contraindications include asthma, chronic obstructive pulmonary disease, peripheral vascular disease and uncontrolled heart failure.

Topiramate

1. 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.
2. Topiramate use for migraine prophylaxis is contra-indicated in pregnancy and in women of child-bearing potential if not using an effective method of contraception. Ensure they are offered suitable contraception. See note 6 (MHRA Drug Safety Update) for advice on contraception and counselling and advice for patients
   1. See resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation.
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 closure glaucoma (see section 4.8.1 Control of the epilepsies).
6. MHRA Drug Safety Update (July 2022): Topiramate (Topamax): start of safety review triggered by a study reporting an increased risk of neurodevelopmental disabilities in children with prenatal exposure
   1. A new safety review has been by triggered by a large observational study reporting that prenatal exposure to topiramate is associated with an increased risk of autism spectrum disorders, intellectual disability, and neurodevelopmental disorders
   2. Ensure any patients of childbearing potential know to use highly effective contraception throughout treatment with topiramate
   3. Counsel patients on the importance of avoiding pregnancy during topiramate use due to these emerging data and also the established increased risks of major congenital malformations and fetal growth restriction in babies exposed to topiramate in-utero
   4. Topiramate may reduce the effectiveness of steroidal contraceptives, including oral contraceptives, therefore consider alternative or concomitant methods. See the Drug Safety Update for advice
   5. Do not prescribe topiramate during pregnancy for migraine prophylaxis
   6. For advice to give to patients, see the Drug Safety Update.

Amitriptyline

1. To minimise side effects, treatment should be started at a low dose (10mg at night). Local specialist advice is to aim for 100mg at night. The maximum recommended dose is 150mg at night.

Other drugs

1. The use of sodium valproate, pizotifen and gabapentin for migraine prophylaxis has been superseded.
2. Botulinum toxin type A is recommended as an option for prophylaxis of headaches in adults with chronic 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.

Studies suggest that approximately 10% of children suffer with migraine. The characteristics are different from adults - headaches are shorter, more commonly bilateral and nausea, phonophobia and photophobia may be absent. Paracetamol and ibuprofen are useful for acute attacks. Sumatriptan nasal spray is licensed in children aged 12 years or over; sumatriptan and zolmitriptan are occasionally recommended by specialist paediatricians for off-label use, more information can be found in the BNF for children. Pizotifen and propranolol are useful preventative drugs. Doses are in the BNF for children.

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.