NICE CG150 - Headaches in over 12s: diagnosis and management (updated Nov 2015) provides guidance on the diagnosis and management of headache and migraine.
NHS England (NHSE) has published new prescribing
guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). One of these conditions is infrequent migraine.
Many migraine treatments e.g. analgesia, anti-sickness medicines, and sumatriptan are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click
here for further information, exceptions, and a patient leaflet.
It is important to differentiate between migraine and cluster headaches. The treatments are different.
- Pain can occur in any location.
- Pain is severe and throbbing. Patients want to lie down.
- Attack lasts 4-72 hours.
- Nausea, vomiting, photophobia or phonophobia.
- Unilateral pain (around the eye, above the eye and along the side
of the head/face)
- Pain is very severe and piercing. Patients pace the room.
- Attack lasts 15-180 minutes and come in clusters.
- Autonomic features around the eye on side of pain
Migraine patients may be sensitive to changes in their internal and external environments. It is therefore important to keep mealtimes, drinking and sleeping patterns as constant as possible. Trigger factors may be important for some individuals but most attacks have no obvious trigger. Trigger factors which have been identified include:
- relaxation after stress;
- changes in habit (missing meals, missing sleep/lying in late);
- bright lights and loud noise;
- dietary factors: some alcoholic drinks, cheese, citrus fruit, chocolate;
- hormonal fluctuations.
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:
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:
5HT1 agonists (triptans)
- 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.
- Should be taken as soon as possible after the onset of headache.
- Triptans are associated with return of symptoms within 48 hours in 20-50% of patients who have initially responded.
- 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.
- 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 two hours after the first dose. Subcutaneous sumatriptan can be repeated after one hour for a recurring headache.
- Patients who overuse triptans may develop daily migraine-like headaches or an increase in migraine frequency. See "Medication Overuse Headache" below for guidance.
- 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
- 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
- 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:
- Triptans, opioids, ergots or combination analgesic medications on 10 days per month or more, or
- Paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more
- 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, 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
Second line option
- Licensed for migraine prophylaxis. Start at a low dose and attempt to titrate up to 160mg SR daily.
- Contraindications include asthma, chronic obstructive pulmonary disease, peripheral vascular disease and uncontrolled heart failure.
- 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.
- 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. 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.
- See resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation
- Topiramate is associated with decreased appetite. Patients should be monitored for weight loss.
- Adequate hydration is advised to reduce the risk for renal stone formation.
- For CSM warning on secondary angle closure glaucoma (see section 4.8.1 Control of the epilepsies)
- 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.
- The use of sodium valproate, pizotifen and gabapentin for migraine prophylaxis has been superseded.
- 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).
- 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 in children
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
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.
4. Central Nervous System >
Management of migraine
- First line
- Second line