Migraine

The SWL episodic and chronic 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.

Episodic and Chronic Migraine SWL Drug Pathway

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