Migraine in adults

Migraine is defined as at least 5 lifetime attacks of headache lasting 4 to 72 hours with at least two of the following pain characteristics:

• Unilateral
• Pulsating
• Moderate or severe intensity

And the headache is associated with at least one of:

• Nausea/vomiting
• Photophobia
• Phonophobia

And no more likely cause of headache identified.

Migraine may or may not be preceded by an aura.

Aura

Aura symptoms, if present, are fully reversible and typically consist of:

• Visual symptoms such as zigzag lines and/or scotoma.
• Sensory symptoms such as unilateral pins and needles or numbness.
• Speech and/or language symptoms such as dysphasia.

Aura symptoms typically last 5-60 minutes and are followed by headache within 60 minutes. Two or more aura symptoms may follow in succession.

Chronic migraine

Chronic migraine is defined as headache on 15 or more days a month, for at least 3 months where at least 8 of the days fit the migraine criteria. Medication overuse is common in chronic migraine and dealing with this will often result in reverting back to episodic migraine.

Please refer to BNF/SPC for full prescribing information

First line

• Aspirin 900 mg (max 4 times/24h)
• Ibuprofen 400-600 mg (max 4 times/24h)
• Cyclizine 50 mg (max 3 times/24h)

Second line

Triptans (max 2 doses/24 hours, max 6-8 days a month - high risk of medication overuse headache). Response to triptans is variable so if a patient does not respond to one triptan after use in three separate attacks, it is reasonable to try another.

Triptans are contraindicated in coronary heart disease, vascular disease or history of stroke. They should not be used in patients with history of severe hypertension or current uncontrolled hypertension (BP > 140/90). Not licensed in over 65s and should be used with caution.

Sumatriptan 50mg/100mg oral tablet is first line.

If this fails an alternative triptan should be tried. Rizatriptan 10 mg oral tablet, oro-dispersible tablet or melt (5mg maximum if taking propranolol) is second line formulary choice.

Alternatives are:

• Naratriptan 2.5mg oral tablet
• Frovatriptan 2.5mg oral tablet
• Almotriptan 12.5 mg oral tablet
• Zolmitriptan 2.5mg oral tablet or oro-dispersible tablet, 5mg nasal
• Sumatriptan 6 mg injection, 20 mg nasal
• Eletriptan 40 mg oral tablet (note Eletriptan is significantly more expensive than the others)

Naratriptan and Frovatriptan have a slower onset but longer half-life so can be use as mini-prophylaxis menstrual migraine (2.5mg bd for 5 days starting 2 days before period)

Triptans should be taken at onset of headache (not onset of aura). A second dose should not be taken for the same headache if first dose not effective. If first dose effective but symptoms recur a second dose can be taken as long as at least 2 hours since first dose (4 hours for naratriptan)

Side effects tightness in jaw, throat, chest and pins and needles in face.

Third line

Rimegepant (Vydura) 75mg tablets taken at onset of headache. This is a calcitonin gene-related peptide (CGRP) receptor antagonist. It is taken in a similar way to triptans at the onset of headache. It is very expensive (£12.90 a tablet) and generally much less effective than triptans but is SMC approved for use in treatment of acute migraine with or without aura in adults where:

• NSAIDs and paracetamol have given inadequate relief, and
• trials of at least 2 triptans have failed to give adequate relief, or
• triptans are contra-indicated

Avoid codeine/opioids

Do not use gabapentinoids in migraine management.

When to consider preventative medication

• Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment.
• Acute treatments are either contraindicated or ineffective.
• The person is at risk of medication overuse headache (MOH) due to frequent use of acute drugs.

Note it is essential to consider medication overuse headache before starting preventative treatment as the appropriate management of medication overuse is drug withdrawal.

Patients must be counselled that prophylaxis aims to reduce the frequency and severity of attacks only, not abolish them. Patients should be told to expect side effects initially and use each treatment for at least 3 months. Often the reason for ineffectiveness is lack of perseverance or medication overuse.

A successful outcome is 50% reduction in headache days in episodic migraine or 30% reduction in headache days in chronic migraine.

Lifestyle advice

Common triggers:

• Sleep deprivation/excess
• Missing meals
• Exercise
• Stress - either too much or relaxing after stress
• Caffeine
• Alcohol

Suggest headache diary. The Migraine Trust has a downloadable template.

Sleepio app for sleep management. Self management advice at the migraine trust

Medication options

Please refer to BNF/SPC for full prescribing information

When swapping between preventative medications, titrate one down over 2 weeks before starting the next.

Beta Blockers

• Propranolol 20mg BD titrating up 10-20mg bd every 2 weeks to 80mg BD.
• Propranolol MR is an alternative - 80mg OD increasing to 160mg OD.
• Contra-indicated in asthma, heart failure, PVD, depression and should not be used in patients taking verapamil
• Side effects bradycardia, hypotension, fatigue, sexual dysfunction, wheezing

Tricyclics

• Amitriptyline 10mg daily, increasing by 10mg a week, aiming for 50mg daily, at or 1-2 hours before bedtime
• First-line when migraine coexists with:
  • tension-type headache
  • another chronic pain condition
  • disturbed sleep
  • depression
• Side effects constipation, difficulty with micturition, arrhythmias, syncope, confusion, nausea, dry mouth, drowsiness, weight gain.
• Nortriptyline is an alternative and less sedative.

Topiramate

• Topiramate 25mg once daily at night, increasing by 25mg every 2 weeks aiming for 50mg bd.
• If partially effective and well tolerated, can be further titrated to maximum 100md bd.
• Topiramate is teratogenic. It interacts with oral contraception to make it ineffective (only coil or depot effective). It should be avoided in women of childbearing age except if women are counselled about effects on foetus and using 'highly effective' contraception - coil or depot plus condoms. See FSRH statement
• Avoid if breast feeding.
• Avoid with history of glaucoma or renal stones or anorexia nervosa.
• Interacts with digoxin, metformin, thiazides, acetazolamide. See BNF/SPC for further details.
• Side effects acute glaucoma, peripheral paraesthesia, fatigue, nausea, diarrhoea, weight loss, taste change, concentration difficulties, word finding difficulties, insomnia, anxiety, depression.

Candesartan

• Start 4mg daily increasing by 4mg  every 1-2 weeks aiming for 16mg daily
• Check baseline U&E and monitor U&E during titration.
• Should not be used in pregnancy and women of child bearing age should be on highly effective contraception.
• Avoid in breast feeding
• Avoid in patients with renal artery stenosis, hypotension, renal impairment or history of angio-oedema
• Interacts with lithium, caution with spironolactone. See SPC/BNF for further details.
• Side effects hypotension, renal impairment and cough.

Others

• Pizotifen 0.5-1.5mg
  • Limited evidence base but widely used.
  • may cause weight gain

Riboflavin 400mg once daily is mentioned in NICE but not SIGN guideline. Magnesium, Feverfew and Melatonin are not mentioned in either and therefore not recommended.

Oral CGRP inhibitors

• Rimegepant 75mg alternate days can be used as a preventative treatment for patients with episodic migraine who have at least 4 migraine attacks per month, but fewer than 15 headache days per month and who have had prior failure on three or more migraine preventive treatments.
• It is SMC approved for this indication and can be prescribed in primary care but for many patients a referral or advice referral would be more appropriate if three or more preventative treatments have failed.

Before referral

• ensure adequate trial of at least 3 of the preventative treatments above - 2 months at therapeutic doses of each of the options.
• consider medication overuse headache
• ensure patient is keeping a headache diary
• if referral is essentially for CT scan then there is open access for CT head in D&G but remember:
  • There are incidental findings in up to 10% of CT heads
  • Radiation dose is 100 chest xrays
  • Studies suggest it doesn't provide long-lasting reassurance

Refer patients

• where there is diagnostic uncertainty
• with disabling migraine which fails to respond to primary care management (at least 3 of the options above at maximal dose and for 2 months).

Please include details of all options tried already, including the reason for not continuing.

There are secondary care only treatments available (Botox injections, flunarizine and injectable CGRP monoclonal antibodies) but there are strict inclusion criteria requiring all of the above treatments to have been tried first.