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migrane Treatment

It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines.

Acute treatment

  • first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
  • for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
  • if the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan

Prophylaxis

  • prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.
  • NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
  • if these measures fail NICE recommends 'a course of up to 10 sessions of acupuncture over 5-8 weeks'
  • NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people'
  • for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'
  • treatment options that may be considered by specialists, but fall outside the NICE guidelines:
    • candesartan: recommended by the British Association for the Study of Headache guidelines
    • monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor: examples include erenumab
  • pizotifen is no longer recommended. Adverse effects such as weight gain & drowsiness are common

*caution should be exercised with young patients as acute dystonic reactions may develop