Treatment guidelines for migraine
Algorithm
GPGoals of treatment
- Acute medications: relieve the headache and allow the return to normal functioning within 2 hours of treatment.
- Prophylactic medications: reduce the frequency of headaches by at least 50%.
Treatment choice
- All patients should be provided with behavioural and/or physical therapies, such as relaxation, biofeedback, stress reduction strategies, cervical manipulation, massage, exercise and the avoidance of migraine triggers.
- All patients should receive acute medications.
Recommended acute medications include:- Aspirin and NSAIDs in large doses, paracetamol plus domperidone or aspirin or paracetamol plus metoclopramide are all recommended for mild to moderate migraine. These drugs should be taken as early as possible and before the headache develops, including during the aura.
- Oral triptans are recommended for moderate to severe migraine, and should be taken as soon as possible after the headache starts, preferably when it is mild in intensity.
- The oral triptans are suitable for most patients. However, patients who have unpredictable attacks may benefit from orally dispersible tablet formulations (although they are not absorbed in the mouth), or nasal spray formulations. Patients with particularly severe attacks, those with a need for rapid response and those with nausea and (especially) vomiting may require nasal spray or subcutaneous formulations.
- Patients should have access to appropriate acute medications for use as rescue and/or at follow-up when the initial medication fails.
- Selected patients may also require prophylactic medications. The criteria
for their use are frequent attacks (≥ 4 attacks per month) or
resistance to or contraindications to appropriate acute medications.
Recommended prophylactic medications include:
- Beta-blockers (propranolol, metoprolol, timolol or nadolol). These drugs may be started at low doses and escalated if necessary
- Anticonvulsants, such as sodium valproate*
- Antidepressants, such as amitriptyline*
*Have been shown to be effective but use with caution as these drugs are not licensed for migraine in the UK. - Topiramate is likely to be licensed soon for migraine prophylaxis in the UK.
- Some complementary medications, including feverfew, magnesium, vitamin B2, acupuncture and butterbur may be used in addition to (not instead of) the patient’s existing acute and/or prophylactic therapies.
- Patients who do not respond to repeated courses of acute and prophylactic medications should be referred to a neurologist or headache specialist for care.
References
- Dowson AJ, Lipscombe S, Sender J et al. New guidelines for the management of migraine in primary care. Curr Med Res Opin 2002;18:414–39.
- Migraine in Primary Care Advisors. Guidelines for the management of migraine in primary care, 2nd Edition. Guidelines 2004;22:127–31.
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