Migraine is an extremely common condition. It is not possible for all patients with migraine to be assessed in the Neurology department.
Before referring patients with migraine to the Neurology department, please follow the management guidelines and try at least three prophylactic agents before referring patients.
Please seek advice through the advice and referral system if you think that the patient may have cluster headache or trigeminal neuralgia.
Migraine is characterised by recurrent episodes of moderate to severe headaches, unilateral or bilateral and frequently throbbing. There may be associated nausea/vomiting, and light, noise and/or motion sensitivity.
For more information on clinical features, please visit the Headache Management System website.
Consultation guide
Manage expectations – explain that migraine cannot be cured but can be effectively managed in most cases.
For general principals and when to scan, please visit the Headache Management System website.
Treatment
Lifestyle remains an important factor in migraine. Patients should be encouraged to:
- eat regular meals
- keep well hydrated
- avoid too much caffeine, energy drinks and alcohol
- maintain a regular sleep pattern
Acute treatment
General principals
- Migraine attacks should be treated early – when headache (not aura) starts
- Migraines respond best to 'triple therapy' – the combination of NSAIDS and prokinetic antiemetic (to make sure that the analgesics are being absorbed) and a triptan
- Mild attacks – paracetamol 1000mg ± Ibuprofen (200-800mg)
- Moderate/severe attacks – NSAID or paracetamol + triptan + prokinetic antiemetic
- Patients should be made aware of medication-overuse headache (see below)
- Opioids should be avoided where possible
Simple analgesics
| Drug | Dose | Max dose 24 hours |
|---|---|---|
| Aspirin | 300-900mg | 4000mg |
| Diclofenac | 25mg | 150mg |
| Ibuprofen | 200-600mg | 2400mg |
| Ketoprofen | 75-150mg | 150mg |
| Naproxen | 250-500mg | 1000mg |
| Paracetamol | 1000mg | 4000mg |
| Tolfenamic acid | 200mg | 400mg |
Triptans
| Drug | Dose | Max dose 24 hours |
|---|---|---|
| Almotriptan | 12.5mg | 25mg |
| Eletriptan | 40mg | 80mg |
| Frovatriptan | 2.5mg | 5mg |
| Naratriptan | 2.5mg | 5mg |
| Rizatriptan | 10mg | 20mg |
| Sumatriptan | 50-100mg (oral) | 300mg |
| 10-20mg (nasal spray) | 40mg | |
| 3 - 6mg (subcut injection) | 12mg | |
| Zolmitriptan | 2.5-5mg (oral) | 10mg |
| 5mg (nasal spray) | 10mg |
Prokinetic antiemetics
If the vomiting is very early and is likely to prevent oral medication from being absorbed consider using Buccastem and Maxalt wafers – the buccal versions of prochlorperazine and rizatriptan respectively.
| Drug | Dose | Max dose 24 hours |
|---|---|---|
| Domperidone | 10mg | 30mg |
| Prochlorperazine | 10mg | 30mg |
| Metoclopramide | 10mg | 30mg |
Medication-overuse headache
Medication-overuse headache may occur in patients with chronic migraine who frequently use acute migraine medication (Paracetamol or Ibuprofen ≥15 days a month) or (Triptans or Opiated or mixed (≥10 days a month).
Although this should be discussed with patients, many are unable to reduce acute pain medication until established on preventative medication.
For more information on acute treatment, please visit the Headache Management System website.
Preventative medication
Starting, stopping and switching:
- Start if on average ≥1 attack per week
- Prescribe according to other co-morbidities (i.e. if asthma – betablockers contraindicated)
- Start low and increase slow (i.e. small increments evert 1-2 weeks)
- Encourage patient to keep simple headache diary
- Unless any adverse effects, continue for 3-4 months before switching
- If <50% effective (severity or frequency of migraines) then switch
- If possible, slowly decrease and stop after 12 months. Restart if necessary
If you are struggling to control a patient's headaches despite following the guidance, please get in touch via the advice and referral service. It is important that you include details of:
- which medications have been tried
- the maximum dose reached, and
- the reason for discontinuation
Also, please follow the principles of how to make a good Neurology referral:
| Drug | Start dose | Target daily dose |
|---|---|---|
| Amitriptyline | 10mg | 25-150mg |
| Candesartan | 2mg | 8-16mg |
| Propranolol | 20mg | 240mg |
| Topiramate | 25mg | 25-250mg |
For more information on migraine preventatives, please visit the Headache Management System website.
Specific situations
- Menstrual migraine
- Migraine in pregnancy
When to refer
Referral to secondary care should be done via the advice and referral system. Please follow the guidelines on how to make a good Neurology referral:
- Chronic migraine (≥15 days headache a month)
- Failed on 3+ oral preventatives
- If you think that it is not migraine but a more complex headache (e.g. cluster headache/TAC or trigeminal neuralgia)
In addition to following the how to make a good Neurology referral guidance, please state:
- Headache frequency
- Which preventatives have been trialled
- Dose trialled
- Reason for discontinuation
- Suspected diagnosis
Summary
Migraine?
- Yes: lifestyle advice and acute treatment
- No: consider alternative diagnosis
≥1 attack a week?
- Yes: start migraine preventative
- No: acute treatment only
50% reduction in symptoms?
- Yes: continue preventative, but consider reducing and stopping after 12 months
- No: switch preventative
Failed ≥3 preventatives?
- Yes: consider Headache Clinic referral
- No: switch preventative
≥15 headache days a month?
- Yes: refer to Headache Clinic
- No: acute treatment only
Last reviewed: 11 December 2023