Neurology

The South West London clinical migraine drug pathway is based on national recommendations in line with National Institute for health and Care Excellence (NICE) and British Association for the Study of Headache (BASH) guidance. They have been developed through collaboration between SWL Interface and Secondary Care Prescribing Support (ISPS) and North East London Medicines Management Optimisation team in consultation with clinicians and relevant groups.
These guidelines aim to support clinicians to deliver enhanced patient care and improve outcomes in neurology patients with migraines.
This webpage is kept under review and reflects the latest guidance at the time of publication. It remains the responsibility of prescribers to ensure they adhere to the latest guidelines, license changes and product availability.

SWL Headache Pathway

Headache Referral and Management Guideline in adults

Introduction

  • SWL headache pathway
  • This guideline outlines the headache referral and management pathway for adults (18 years or older) in NHS South West London and signposts to national and local guidance where appropriate. Recommendations are based on  NICE Guidance: Headaches in over 12s: diagnosis and management,  BASH headache management guidelines and NICE Clinical Knowledge Summaries.
  • Target audience: Primary care practitioners in NHS South West London.
  • Please note: This guidance has been developed for use in adult patients in SWL and does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

Recommendations

Assessment and diagnosis

  • The SWL headache pathway and NICE CKS Headache – assessment provides information on how to assess a patient presenting with headache to accurately diagnosis the type of headache. This includes history taking, examination and arranging investigations if necessary.
  • Assessment should include exclusion of red and amber flags suggesting a potentially serious underlying cause, requiring emergency admission or urgent specialist referral.
  • Consider medication overuse headache, which is defined as ‘Headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of one or more drugs that can be taken for acute and/or symptomatic treatment of headache, for more than 3 months.’ See NICE CKS Headache – medication overuse for more information.
  • At first Primary Care review, give headache diary to inform further care if needed.
  • Less common benign diagnoses to consider:
    • Cervicogenic headache (overdiagnosed)
    • Primary stabbing headache
    • Trigeminal neuralgia
    • Primary sex headache
  • If diagnosis still unclear after second Primary Care review, consider electronic advice discussion if specific query or referral to local neurology headache services.

Management of Tension Type Headache

  • See NICE CKS Headache – tension-type for more information.
  • If occurs less than 8 days per month, advise to take simple analgesia and warn about medication overuse.
  • If occurs more than 8 days per month, consider Amitriptyline – see section 2.4.2 for dosing information. Refer to BNF and SmPC for full product information. Reconsider diagnosis (?migraine).

Management of Cluster Headaches (new diagnosis or relapse)

Management of Migraine

Acute treatment of migraine

Prevention of migraine

  • SWL Headache pathway
  • See NICE CKS: Drugs for the prevention of migraine
  • Consider preventive treatment in adults who are not pregnant or breastfeeding if:
    • Attacks are frequent or prolonged and severe despite appropriate acute treatment.
    • The person is at risk of medication overuse headache.
  • Do not initiate preventive treatment in primary care for women who are pregnant or breastfeeding. Seek specialist advice if preventive treatment for migraine is needed during pregnancy or if planning pregnancy, as many preventive drugs have limited evidence of safety or are contraindicated in these groups.
  • When selecting a preventive treatment, consider the patient’s other co-morbidities, whether they have child-bearing potential, previous treatment, personal preference, drug interactions and side effect profiles of the various treatments.
  • Drug treatment should be initiated at low dose and titrated according to efficacy and tolerability.
  • Treatments may take up to 6 weeks to provide a benefit.
  • Arrange follow up to monitor effectiveness, titrate dose and assess for adverse effects. A headache diary may help evaluate response to treatment.
  • After 6 to12 months of successful therapy, review the need for continuing preventive treatment and consider gradual drug withdrawal.
  • The SWL Episodic and Chronic Migraine Drug Pathways has information on the pathway for high cost drugs for episodic and chronic migraine.
  • Recommended preventive treatment options for migraine (listed in alphabetical order) include:
    • Amitriptyline (RAG rating: Green)
    • Candesartan (RAG rating: Green)
      • Migraine prophylaxis is an approved, off-label indication.
      • Start: 4mg every night, increase dose if tolerated by 4mg every week.
      • Target: 16mg every night.
      • In exceptional cases, if partial response to 16mg dose, consider increasing further by 4mg every week. Max: 32mg every night.
      • Monitor renal function at baseline, 1 to 2 weeks after starting candesartan, after each increase in dose and regularly throughout treatment.
      • The use of angiotensin II receptor antagonists is not recommended during the first trimester of pregnancy and contraindicated during the second and third trimesters of pregnancy.
      • Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.
    • Propranolol(RAG rating: Green)
    • Topiramate
      • New regulatory measures have been introduced because there is evidence that the use of topiramate during pregnancy is associated with significant harm to the unborn child.
      • The use of topiramate is now contraindicated:
        • In pregnancy for prophylaxis of migraine
        • In women of childbearing potential unless the conditions of the Pregnancy Prevention Programme (PPP) are fulfilled.
      • Refer to MHRA Topiramate safety measures for further information and support material.
      • New patients:
        • For licensed indication (e.g. migraine prophylaxis) and conditions of PPP met: RAG rating Amber 1 – The GP can initiate topiramate following recommendation by a specialist via Advice and Guidance. It is the responsibility of the initiating clinician* to ensure that the requirements of the PPP are fulfilled including ensuring suitable contraception is in place. The initiating clinician must complete the Risk Awareness Form (RAF) for migraine  on initiation and annually thereafter.
        • *If the GP initiates treatment under Amber 1 following Advice and Guidance, it is the responsibility of the GP to ensure the requirements of the PPP are met and RAF is completed.
        • For licensed indication and conditions of PPP NOT met (even when informed choice by patients) Note: This makes the use unlicensed: RAG ratingRed (will become Amber 3 once shared care agreement is approved).
      • Existing patients:
        • Prescribing continues in primary care following pre-existing arrangements.  Refer to Flow Diagram Outlining How to Manage Existing Female Patients of Childbearing Potential Prescribed Topiramate in Primary Care on GP Teamnet.
        • If the patient has been managed in primary care for a significant period of time, then the primary care healthcare professional (HCP) will complete the PPP and RAF (and at annual review), if it is within their competency. If the patient has a complex medical history, then the primary care HCP should seek advice from the specialist.
      • Dose as per BNF
      • Refer to the BNF and SmPC for full product information including contraindications, cautions, drug interactions and side effects.
    • Valproate
      • Refer to MHRA alert female  and MHRA alert male for information on the new regulatory requirements.
      • New patients (male and female):
        • For unlicensed indications (as defined by SWL Valproate policy e.g. migraine prophylaxis): RAG ratingRed (will become Amber 3 once shared care agreement is approved)  
      • Existing female patients (of child bearing potential),RAG ratingAmber 2, who are taking valproate for prophylaxis of migraine must be referred back to the specialist for completion of an Annual Risk Acknowledgement Form (ARAF).
      • Annual ARAF reviews must be completed by the initiating specialist.
      • Existing male patients,RAG rating Amber 2:
      • Refer to the BNF and SmPC  for full product information including contraindications, cautions, drug interactions and side effects.

References

v1.1 Approved by: Integrated medicines optimisation committee (IMOC) January 2025

Episodic and Chronic Migraine SWL Drug Pathway

Primary care acute migraine prescribing guidelines for use in adults

This guideline is intended for use by clinicians in primary care for the acute treatment of migraine in adults (age 18 years and above) and is also available as a visual summary flowchart.

Please note the following is outside the scope of this guideline:

Introduction

Recommendations

Simple analgesia

  • Offer simple analgesia (encourage Self Care) such as:
    • Ibuprofen (400 mg) — if ineffective, consider increasing to 600 mg or
    • Aspirin (900 mg) or
    • Paracetamol (1000 mg).
      • These treatments should be used for 1 dose and should be taken as soon as migraine symptoms develop.

Triptans

  • Offer a triptan, alone or in combination with paracetamol or an NSAID:
    • 1st choice: Oral sumatriptan 50 to 100 mg (maximum 300 mg per 24 hours).
    • If increased nausea with oral sumatriptan, consider zolmitriptan orodispersible tablet 2.5 to 5 mg (maximum 10 mg per 24 hours).
  • An alternative triptan should be tried if initial choice proves ineffective.
    • If lack of efficacy, consider rizatriptan orodispersible tablet 10 mg (maximum 20 mg per 24 hours) or eletriptan tablet 40 mg (maximum 80 mg per 24 hours).
    • If headache recurrence within 24 hours, consider eletriptan tablet 40 mg (maximum 80 mg per 24 hours) or frovatriptan tablet 2.5 mg (maximum 5 mg per 24 hours).
    • If patient experiencing side effects, consider naratriptan tablet 2.5 mg (maximum 5 mg per 24 hours) or eletriptan tablet 40 mg (maximum 80 mg per 24 hours).
    • If severe vomiting or need for rapid onset, consider a non-oral formulation such as zolmitriptan nasal spray 5 mg (maximum 2 sprays per 24 hours) or sumatriptan subcutaneous injection 3 to 6 mg (maximum 2 injections per 24 hours).
  • Refer to the BNF and SmPC for full product information including dose, contraindications, cautions, drug interactions and side effects.
  • Combination with an NSAID with a long half-life (such as naproxen 500 mg) may be most effective.
  • Triptans are most effective if taken early in the headache phase of an attack (not aura phase). If they have aura, triptans should be taken at the start of the headache and not at the start of the aura (unless the aura and headache start simultaneously).
  • If symptoms recur, a second dose can be given with a minimum 2 hour interval (minimum 1 hour interval for sumatriptan subcutaneous injection and minimum 4 hour interval for naratriptan tablet), not exceeding maximum 24 hour dose as per BNF and SmPC.
  • Consider offering an anti-emetic (such as metoclopramide 10 mg or prochlorperazine 10 mg) in addition to other acute medication, even in the absence of nausea and vomiting.
    • Metoclopramide should not be used regularly due to the risk of extrapyramidal side effects.

Triptan failure / intolerance

  • Effective triptan treatment is defined as improvement of headache to mild or absent, absence or minimal non-pain symptoms with no drug-related adverse events for at least 24 hours.
  • If they have aura, triptans should be taken at the start of the headache and not at the start of the aura (unless the aura and headache start simultaneously).
  • After TWO treatment failures with a particular triptan or intolerance to triptans, an alternative treatment is recommended.

Rimegepant

  • Rimegepant is approved for use across SWL as Amber 1 (i.e. on the advice of a specialist) for the acute treatment of migraine with or without aura, in line with NICE: Overview of Rimegepant for treating migraine Guidance, via Advice and Guidance, if for previous migraines:
    • At least 2 triptans were tried and did not work well enough or
    • Triptans were contraindicated or not tolerated, and nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were tried but did not work well enough
  • The maximum dose per day of rimegepant is 75mg. If considering rimegepant for acute migraine treatment in patients who are already taking it regularly for migraine prophylaxis, seek Advice and Guidance from neurology.
  • If needed, combine rimegepant with a NSAID.

Medication Overuse Headache (MOH)

  • MOH can be avoided by restricting acute medication to a maximum of 2 days per week.
  • Opioids (including codeine) should not be used for acute treatment.
  • To avoid medication overuse headache
    • Triptans should not be taken for more than 10 days each month
    • Simple analgesia should not be used more than 15 days per month
  • For people with MOH, advise abrupt cessation of all overused simple analgesics and triptans for at least 1 month, and explain the potential for headache symptoms to worsen in the short term before they improve.
  • For more information, see the CKS topic on Headache – medication overuse | Health topics A to Z | CKS | NICE

Special considerations

  • Menstrual migraine (approved, unlicensed indication): Frovatriptan 2.5 mg (dose schedule as per BNF) can be considered (after NSAIDS) if cycle is regular/predictable.
  • Ensure that women who have migraine with aura are not using combined hormonal contraception, as this is contraindicated.
  • For further information on contraceptive use and migraine, see the CKS topic on Contraception – assessment.

References

v1.1 Approved by: Integrated medicines optimisation committee (IMOC) January 2025