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SIGN decision support

Preventive therapy

Pharmacological management of migraine (SIGN)
Healthcare Improvement Scotland
  • Consider if migraine is disabling and reducing quality of life, eg frequent attacks (>1 per week on average) or prolonged severe attacks.
  • Which medication to try first depends on patient comorbidities, other health issues, drug interactions and patient preference.
  • Start at low dose and gradually increase according to efficacy and tolerability.
  • Good response is a 50% reduction in severity and frequency of attacks.
  • Treatment failure is a lack of response to the highest tolerated dose used for 3 months.
  • Consider referral to neurology or a headache clinic if three or more therapies have failed.
  • If the patient responds well to prophylactic treatment a trial of gradual drug withdrawal should be considered after 6 months to 1 year.

Lifestyle advice

For patients with migraine maintaining a regular routine is important, including the following:

  • Regular meals, adequate hydration with water, sleep and exercise
  • Avoiding specific triggers if known
  • Activities that encourage relaxation such as mindfulness, yoga or meditation.

First-line therapies

RecommendationPropranolol:  target does 80 mg twice a day

RecommendationTopiramate: target dose 50 mg twice a day (use if propranolol fails)

RecommendationBefore commencing treatment women should be informed of:

  • the risks associated with taking topiramate during pregnancy
  • the risk that potentially harmful exposure to topiramate may occur before a women is aware she is pregnant
  • the need to use highly-effective contraception
  • the need to seek further advice on migraine prophylaxis if pregnant or planning a pregnancy.

RecommendationAmitriptyline: target dose 30–50 mg at night. In patients who cannot tolerate amitriptyline a less sedating tricyclic antidepressant should be considered. 

RecommendationCandesartan: target dose 16 mg daily.

Good practice point tickUse of candesartan should be avoided during pregnancy and breastfeeding. Women using candesartan who are planning to become pregnant, or who are pregnant, should seek advice from their healthcare professional on switching to another therapy.

 

Other therapies

RecommendationSodium valproate: target dose 600 mg twice a day (in patients over age 55).

Good practice point tickAlthough initiation of valproate is not recommended for those under the age of 55, for those who are on it and who fulfil MHRA requirements, inform the patient of the risks to children exposed to valproate in utero and the need to use effective contraception - see www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements.

Check the Medicines and Healthcare products Regulatory Agency (MHRA) website for current advice.

Pizotifen: target dose 3–4.5 mg (lacking evidence but this is a well-established, widely-used therapy.

Specialist therapies

RecommendationFlunarazine: target dose 10 mg daily.

Good practice point tickFlunarazine should be avoided during pregnancy and breastfeeding. Women using flunarazine who are planning to become pregnant, or who are pregnant, should seek advice from their healthcare professional on switching to another therapy.

RecommendationBotulinum toxin A: for patients with chronic migraine where medication overuse has been addressed and patients have been appropriately treated with three or more oral migraine prophylactic treatments. It is not recommended for patients with episodic migraine.

Good practice point tickBotulinum toxin A should only be administered by appropriately trained individuals under the supervision of a headache clinic or the local neurology service.

 

Calcitonin-gene-related peptide (CGRP) monoclonal antibodies:

RecommendationErenumab, fremanezumab, galcanezumab and eptinezumab are recommended for the prophylactic treatment of patients with chronic migraine where medication overuse has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.

RecommendationFremanezumab, galcenezumab and eptinezumab can be considered for the prophylactic treatment of patients with episodic migraine where medication overuse has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.

Therapies to avoid in pregnancy

Therapies to avoid during pregnancy or breastfeeding:

  • candesartan
  • topiramate
  • sodium valproate
  • flunarazine
  • CGRP monoclonal antibodies.

RecommendationBefore commencing treatment with topiramate women should be informed of:

  • the risks associated with taking topiramate during pregnancy
  • the risk that potentially harmful exposure to topiramate may occur before a women is aware she is pregnant
  • the need to use highly-effective contraception
  • the need to seek further advice on migraine prophylaxis if pregnant or planning a pregnancy.

Good practice point tickAlthough initiation of valproate is not recommended for those under the age of 55, for those who are on it and who fulfil MHRA requirements, inform the patient of the risks to children exposed to valproate in utero and the need to use effective contraception - see www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements.

Check the Medicines and Healthcare products Regulatory Agency (MHRA) website for current advice.