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Overview

Recommendations are marked up with an (R) and good-practice points are marked up with a (✓); for further information about the ‘strength’ of recommendations, see the SIGN 155 Quick reference guideline

A treatment path way for the pharmacological management of patients with migraine

Pharmacological management of patients with migraine treatment pathway. Download a PDF of this algorithm

Acute therapies

  • When starting acute treatment, healthcare professionals should warn patients about the risk of developing medication‑overuse headache. (✓)

Aspirin

  • Aspirin (900 mg) is recommended as first‑line treatment for patients with acute migraine. (R)
  • Aspirin, in doses for migraine, is not an analgesic of choice during pregnancy and should not be used in the third trimester of pregnancy. (✓)

Non-steroidal anti-inflammatory drugs

  • Ibuprofen (400 mg) is recommended as first-line treatment for patients with acute migraine. If ineffective, the dose should be increased to 600 mg. (R)

Paracetamol

  • Paracetamol (1000 mg) can be considered for treatment of patients with acute migraine who are unable to take other acute therapies. (R)
  • Due to its safety profile, paracetamol is first choice for the short‑term relief of mild to moderate headache during any trimester of pregnancy. (✓)

Antiemetics

  • Metoclopramide (10 mg) or prochlorperazine (10 mg) can be considered in the treatment of headache in patients with acute migraine. They can be used either as an oral or parenteral formulation depending on presentation and setting. (R)
  • Metoclopramide (10 mg) or prochlorperazine (10 mg) should be considered for patients presenting with migraine-associated symptoms of nausea or vomiting. They can be used either as an oral or parenteral formulation depending on presentation and setting. (R)
  • Metoclopramide should not be used regularly due to the risk of extrapyramidal side-effects. (✓)

Triptans

  • Triptans are recommended as first‑line treatment for patients with acute migraine. The first choice is sumatriptan (50–100 mg), but others should be offered if sumatriptan fails. (R)
  • In patients with severe acute migraine or early vomiting, nasal zolmitriptan or subcutaneous sumatriptan should be considered. (R)
  • Triptans are recommended for the treatment of patients with acute migraine associated with menstruation. (R)
  • Sumatriptan can be considered for treatment of acute migraine in pregnant women in all stages of pregnancy. The risks associated with use should be discussed before commencing treatment. (R)

Combination therapies

  • Combination therapy using sumatriptan (50–85 mg) and naproxen (500 mg) should be considered for the treatment of patients with acute migraine. (R)

Preventative therapies

Beta blockers

  • Propranolol (80–160 mg daily) is recommended as a first-line prophylactic treatment for patients with episodic or chronic migraine. (R)

Topiramate

  • Topiramate (50–100 mg daily) is recommended as a prophylactic treatment for patients with episodic or chronic migraine. (R)
  • Before commencing treatment women who may become pregnant should be advised of the associated risks of topiramate during pregnancy, the need to use effective contraception and the need to seek further advice on migraine prophylaxis if pregnant or planning a pregnancy. (R)

Tricyclic antidepressants

  • Amitriptyline (25–150 mg at night) should be considered as a prophylactic treatment for patients with episodic or chronic migraine. (R)
  • In patients who cannot tolerate amitriptyline a less sedating tricyclic antidepressant should be considered. (R)

Candesartan

  • Candesartan (16 mg daily) can be considered as a prophylactic treatment for patients with episodic or chronic migraine. (R)

Sodium valproate

  • Sodium valproate (400–1500 mg daily) can be considered as a prophylactic treatment for patients with episodic or chronic migraine. (R)
  • Prescribers should be aware that sodium valproate is associated with an increased risk of foetal malformations and poorer cognitive outcomes in children exposed to valproate in utero. For women who may become pregnant sodium valproate should only be considered as a prophylactic treatment when (R):
    • other treatment options have been exhausted
    • patients are using adequate contraception
  • Before commencing treatment women should be informed of (R):
    • the risks associated with taking valproate during pregnancy
    • the risk that potentially harmful exposure to valproate may occur before a woman is aware she is pregnant
    • the need to use effective contraception
    • the need to seek further advice on migraine prophylaxis if pregnant or planning a pregnancy
  • When prescribing sodium valproate for women who may become pregnant the MHRA checklist must be used. (✓)

Calcium channel blockers

  • Flunarizine (10 mg daily) should be considered as a prophylactic treatment for patients with episodic or chronic migraine. (R)

Gabapentin

  • Gabapentin should not be considered as a prophylactic treatment for patients with episodic or chronic migraine. (R)

Botulinum toxin A

  • Botulinum toxin A is not recommended for the prophylactic treatment of patients with episodic migraine. (R)
  • Botulinum toxin A is recommended for the prophylactic treatment of patients with chronic migraine where medication overuse has been addressed and patients have been appropriately treated with three or more oral migraine prophylactic treatments. (R)
  • Botulinum toxin A should only be administered by appropriately trained individuals under the supervision of a headache clinic or the local neurology service. (✓)

Menstrual migraine prophylaxis

  • Frovatriptan (2.5 mg twice daily) should be considered as a prophylactic treatment in women with perimenstrual migraine from two days before until three days after bleeding starts. (R)
  • Zolmitriptan (2.5 mg three times daily) or naratriptan (2.5 mg twice daily) can be considered as alternatives to frovatriptan as prophylactic treatment in women with perimenstrual migraine from two days before until three days after bleeding starts. (R)
  • Women with menstrual-related migraine who are using triptans at other times of the month should be advised that additional perimenstrual prophylaxis increases the risk of developing medication overuse headache. (✓)

Medication-overuse headache

  • In patients overusing acute treatment, medication overuse should be addressed. (R)
  • The choice of strategy to address medication overuse should be tailored to the individual patient and may be influenced by comorbidities. Strategies include (R):
    • abrupt withdrawal alone and preventative treatment may then be considered after a delay
    • abrupt withdrawal and immediately starting preventative treatment
    • starting a preventative treatment without withdrawal
  • Consider withdrawing regular opioids gradually. (✓)
  • Prednisolone should not be used routinely in the management of patients with medication-overuse headache. (R)

Sources of further information

Scottish Intercollegiate Guidelines Network (SIGN). Pharmacological management of migraine, quick reference guide. Edinburgh: SIGN; 2018. (SIGN publication no. 155). 

Available from URL: http://www.sign.ac.uk