| See: Headache Management Guidelines |
4.7.4.1 Treatment of the acute migraine attack |
| Analgesics - for preparations see section 4.7.1 |
| Nausea - domperidone section 4.6 may be helpful. |
| |
| First Line Options |
| GREEN Sumatriptan |
| tablets 50mg |
| nasal spray10mg/ 0.1mL unit dose |
| nasal spray 20mg/0.1mL unit dose |
| GREEN Sumatriptan 3 mg/0.5 ml solution for injection in pre-filled pen |
| Sumatriptan injection (subcutaneous) 6mg/0.5mL syringe |
| GREEN Zolmitriptan |
| Orodispersable tablets 2.5mg |
| |
| Second Line options |
| Patients often warrant a trial of different oral triptans due to individual variability in |
| response, and prescribers should choose a second line product with their patient based on efficacy, tolerability, formulation |
| and cost. |
| |
| NICE TA919 Rimegepant for the acute treatment of migraine in adults. ICB Commissioned |
| Rimegepant is recommended as an option for the acute treatment of migraine with or without aura in adults, |
| only if for previous migraines: |
| > at east 2 triptans were tried and they 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. |
| AMBER Rimegepant 75mg oral lyophilisates (Vydura) See full guidance |
| |
| Back to Main chapter |
4.7.4.2 Prophylaxis of migraine |
| Factors which trigger attacks should be sought. Therapy should be reviewed at 6 monthly intervals as long term |
| prophylaxis with these drugs is undesirable. |
| Amitriptyline is unlicensed for migraine but may be usefully prescribed at a dose of 10mg at night, increasing to a |
| maintenance dose of 50-150mg at night. |
| Sodium valproate (unlicensed) is no longer recommended. This is due to the availability of licensed anti-convulsants (e.g. |
| topiramate) and also the teratogenic risk associated with its use in pregnancy (e.g. unplanned pregnancy). |
| GREEN Amitriptyline (unlicensed) tablets 10mg, 25mg, 50mg |
| GREEN Pizotifen |
| tablets 500 micrograms, 1.5mg |
| elixir 250 micrograms/5mL |
| GREEN Propranolol capsules m/r 80mg |
| GREEN Topiramate capsules NICE CG150 (see section 4.8 for use in epilepsy [AMBER]) |
| RED Flunarizine capsules 5mg, 10mg (Sibelium®) Specialist use only |
| |
| RED Galcanezumab [Emgality 120mg/1mL solution for injection p/f pens] |
| NICE TA659 Galcanezumab is recommended as an option for preventing migraine in adults, only if: |
| > they have 4 or more migraine days a month |
| > at least 3 preventive drug treatments have failed and |
| > the company provides it according to the commercial arrangement |
| CCG Commissioned Blueteq form required |
| RED Erenumab [Aimovig] |
| NICE TA682 Erenumab is recommended as an option for preventing migraine in adults, only if: |
| > they have 4 or more migraine days a month |
| > at least 3 preventive drug treatments have failed |
| > the 140mg dose of erenumab is used and |
| > the company provides it according to the commercial arrangement |
| Stop erenumab after 12 weeks of treatment if: |
| > in episodic migraine [less than 15 headache days a month] the frequency does not reduce by at least 50% |
| > in chronic migraine [15 headache days a month or more with at least 8 of those having features of migraine] the |
| frequency does not reduce by at least 30% |
| |
RED Eptinezumab [Vyepti} ICB Commissioned Blueteq form required
|
| NICE TA871 Eptinezumab is recommend as an option for preventing migraine in adults, only if: |
| > they have 4 or more migraines a month |
| > at least 3 preventative drug treatments have failed |
| > the company provides it according to the commercial arrangement. |
| See full guidance |
| |
| AMBER Rimegepant (Vydura) |
| NICE TA906 Rimegepant is recommended as an option for preventing episodic migraine in adults who have at least 4 and fewer than 15 migraine attacks per month, |
| only if at least 3 preventative treatments have not worked. |
| Stop rimegepant after 12 weeks of treatment if the frequency of migraine attacks does not reduce by at least 50%. |
| See full guidance ICB Commissioned |
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| Treatment of chronic migraine |
| RED Botulinum Toxin A (use of brand with lowest acquisition cost) injection CCG Commissioned |
| NICE TA260 Recommended as an option for the prophylaxis of headaches in adults with chronic migraine) defined as |
| headaches on at least 15 days per month of which at least 8 days are with migraine): |
| ° that has not responded to at least three prior pharmacological prophylaxis therapies and |
| ° whose condition is appropriately managed for medication overuse. |
| |
| RED Fremanezumab solution for injection [Ajovy® 225mg/1.5ml] CCG Commissioned BlueTec form required |
| NICE TA631 Recommended as an option for preventing migraine in adults, only if: |
| º the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least of |
| those having features of migraine |
| ° at least 3 preventative drug treatments have failed and |
| ° the company provides it according to the commercial arrangement |
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| Back to Main chapter |
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