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The acute treatment of migraine

Principles of acute migraine management

  • Conduct specific consultations for headache
  • From the outset, institute systems of detailed history taking, patient education, and eliciting their commitment to care
  • Use a screening algorithm (see below) for the differential diagnosis of headache. The final diagnosis can then be confirmed by further questioning, if necessary
  • Select an acute treatment that is tailored to the needs of the individual patient, using a management algorithm (see last page of this guideline). Assessing the impact of headache on the patient’s daily life with the Migraine Disability Assessment Test or The Headache Impact Testquestionnaire is a key aspect of diagnosis and management
  • Only prescribe treatments that have objective evidence of good efficacy and tolerability
  • Use prospective follow-up procedures and questionnaires (e.g. the Migraine Assessment of Current Therapy questionnaire) to monitor the success of treatment
  • Organise a team approach to headache management in primary care using GP and referral services together with community-based healthcare services (e.g. pharmacists, dentists, opticians, and other professionals)
  • Further details of these principles of care can be found in MIPCA Newsletter Number 8, available to download from the MIPCA website (www.mipca.org.uk)

Screening algorithm

Screening algorithm

Choice of initial acute treatment

  • All patients should be provided with behavioural and/or physical therapies, such as:
    • relaxation
    • biofeedback
    • stress reduction strategies
    • cervical manipulation
    • massage
    • exercise
    • the avoidance of migraine triggers
  • Analgesic-based treatments, e.g. aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) in large doses, paracetamol plus domperidone, or aspirin, or paracetamol plus metoclopramide, are recommended for mild to moderate migraine. These drugs should be taken as early as possible and before the headache develops, including during the aura. However, codeine-based treatments should be avoided due to their known potential for overuse
  • Oral triptans are recommended for moderate to severe migraine, and should be taken as soon as possible after the headache starts, preferably when it is mild in intensity
  • Oral triptans remain the gold standard for acute migraine treatment
  • The intake of all acute treatments should be monitored, due to the risk of overuse and the development of medication overuse headache (MOH) and chronic headaches
  • Guidance on appropriate rescue and second-line medications is given in the table below
Appropriate medications to use when the initial migraine therapy fails
INITIAL MEDICATIONCHOICE OF RESCUE OR FOLLOW-UP MEDICATION IF INITIAL THERAPY FAILS
Analgesic-based therapies Try a second dose
Triptan tablets (conventional tablets or ODT)
Oral triptans (conventional tablets or ODT) Try a second dose
Alternative triptan tablets
Triptan delivered by nasal spray or subcutaneous injection
Nasal spray triptans Try a second dose
Subcutaneous sumatriptan
Subcutaneous sumatriptan Try a second dose
Symptomatic treatments (e.g. anti-emetics, strong analgesics)

ODT=orally disintegrating tablet

Choosing the appropriate triptan in clinical practice

  • Evidence indicates that all tripans, except for naratriptan 2.5 mg, have similar clinical profiles. However, the clinician should choose an appropriate initial triptan based on the chemical and clinical features of the drugs, and the needs of the individual patient
  • Determining the severity of the migraine is key when assessing the patient’s needs, and the MIDAS or HIT-6 questionnaire can be used for this
  • Patients with mild-to-moderate migraine may be effectively treated with a simple analgesic, on its own, or in combination with other compounds
  • Patients with moderate-to-severe migraine, and those that have previously failed on analgesic-based therapy, should be prescribed an oral triptan from the start
  • The algorithm below shows some features of the individual triptans that may help guide the clinician when selecting an appropriate initial treatment for their patients
  • Patients frequently reporting headache recurrence may benefit from frovatriptan 2.5 mg
  • Those unable to tolerate other oral triptans may benefit from almotriptan 12.5 mg, naratriptan 2.5 mg, or frovatriptan 2.5 mg
  • Patients that have unpredictable attacks may benefit from the orally disintegrating tablet (ODT) (although they are not absorbed in the mouth), or nasal spray formulations
  • Patients with particularly severe attacks, those with a need for rapid response, and those with nausea and (especially) vomiting may require the nasal spray or subcutaneous formulations

Choosing the appropriate triptan: initial treatment

Choosing the appropriate triptan

Treatment of menstrual migraine

  • A high proportion of female patients on a GP’s list will be affected by attacks of menstrual migraine (defined as attacks occurring between two days before the onset of menstruation and the first three days of bleeding)
  • Attacks of menstrual migraine are usually more frequent and more severe than those occurring at other times
  • Management strategies for menstrual migraine are the same as those for general migraine, and there should be few problems in managing all migraine attacks experienced by women in primary care
  • An evidence-based review of treatments for menstrual migraine concluded that the following treatments were all effective, and had acceptable safety profiles:
    • sumatriptan at 50 mg or 100 mg or
    • mefenamic acid 500 mg or
    • rizatriptan 10 mg or
    • sumatriptan 85 mg/naproxen 500 mg combination
  • Further studies have demonstrated that almotriptan 12.5 mg, frovatriptan 2.5mg, and zolmitriptan 2.5mg are also effective and well-tolerated for menstrual migraine
  • Predictable menstrual attacks may be managed by perimenstrual prophylaxis with:
    • transcutaneous estradiol 1.5 mg or
    • frovatriptan 2.5 mg bd or
    • naratriptan 1 mg bd or
    • zolmitriptan 2.5 mg bd also showed efficacy in this indication
  • Strategies using contraception may be used to treat menstrual migraine in those requiring effective birth control

MIPCA management algorithm for the treatment of migraine

MIPCA management algorithm for the treatmeant of migraine

full guidelines available from…
Rebecca Salt, Surrey Headache Service, Merrow Park Surgery, Kingfisher Drive, Merrow, Guildford, Surrey GU4 7EP
(Tel – 01483 450755), (Fax – 01483 456740)
www.mipca.org.uk/pdf/newsletters/NL19_Acute.pdf

Migraine in Primary Care Advisors. The acute treatment of migraine. April 2012.
First included: June 2012.