Treatment of the Acute Attack

NHSL Medicines Guidance
NHS Lanarkshire

Analgesics

Preferred list (P)

ASPIRIN

IBUPROFEN

Prescribing Notes:

  • Paracetamol may be considered for acute migraine in patients for whom first-line treatments are unsuitable.
  • Use of simple analgesics (e.g. aspirin, ibuprofen, paracetamol) for 15 days per month or more can lead to medication-overuse headache.
  • The use of opioids should be avoided.

Anti-Emetics

Preferred list (P)

METOCLOPRAMIDE

PROCHLORPERAZINE

Triptans - Oral Route

Preferred list (P)

SUMATRIPTAN

Total list (T)

RIZATRIPTAN

  • The dose of rizatriptan should be reduced to 5mg in patients co-prescribed propranolol and administration separated by at least 2 hours.

ZOLMITRIPTAN

Prescribing Notes

  • Individual patient response to triptans is variable. Current national guidelines suggest that their general efficacy is to work for 2 out of 3 attacks.

  • Where there is no response to an oral triptan consider trialling an alternative oral triptan or a triptan in combination with NSAID or paracetamol.

  • Orodispersible formulations are still absorbed gastrically, so may not work if the patient is vomiting.

  • If migraine is associated with an aura, it is recommended that a triptan is taken at the onset of the headache rather than the onset of the aura.

  • Use of a triptan 10 days per month or more can lead to medication-overuse headache.

Triptans - Other Routes

Total list (T)

ZOLMITRIPTAN nasal spray

  • Acute migraine (≥ 18 yrs): 5 mg administered as a single dose into one nostril.
  • If a second dose is required, it should not be taken within 2 hours of the initial dose.
  • Maximum dose in 24 hours is two 5mg nasal sprays (10 mg).

SUMATRIPTAN 6mg/0.5ml solution for injection pre-filled pen.

  • Acute migraine (≥ 18 yrs): 6 mg administered as a single dose by subcutaneous injection.
  • If there is no response to the first dose, a second dose should not be taken for the same attack.
  • Sumatriptan injection may be taken for subsequent attacks. If the patient has responded to the first dose, but the symptoms recur a second dose may be given in the next 24 hours, provided there is a minimum interval of 1 hour between doses.
  • Maximum dose in 24 hours is two 6 mg injections (12 mg).

Prescribing Notes:

  • Nasal and subcutaneous triptans have a significantly higher acquisition cost and the route of administration may be less desirable than the oral route for many patients.
  • Consider reserving these formulations for use in patients where early or persistent vomiting affects absorption of oral triptans and anti-emetics are not effective.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.