Treatment of acute migraine (Formulary)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

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Soluble simple analgesics (eg paracetamol 1g for mild to moderate migraine, or for all severities of migraine ibuprofen 400mg or soluble aspirin 900mg), if necessary, with an antiemetic, eg metoclopramide 10mg (Drugs used in nausea and vertigo), are often effective if taken early in the attack. Diclofenac or paracetamol suppositories may be an option.

Reserve triptans for patients resistant to simple analgesics and antiemetic therapy; if the headache always progresses to a moderate to severe attack despite patients taking acute therapy when symptoms are still mild, then consider triptans.

Use during the established headache phase and not during the aura phase of an attack.

In triptan responders, approximately one in four attacks do not respond to triptans. Refer to SIGN 155: Pharmacological management of migraine and NICE CG150: Headaches in over 12s: diagnosis and management.

Continue triptan treatment for 3 months and only discontinue at that point if ineffective. If one triptan is ineffective then consider trial of another.

  • Triptans should not be used in ischaemic heart disease or coronary vasospasm (including Prinzmetal’s angina), uncontrolled hypertension and previous myocardial infarction (refer to BNF), or with ergotamine.
  • Advise patients that triptans should be taken on no more than 2 days per week due to the risk of developing medication overuse headache.

Other triptans, eg naratriptan, almotriptan and frovatriptan, may be considered for the treatment of non-responsive episodic migraine; refer to BNF.

For chronic migraine which has failed to respond to 3 or more preventative treatments, botulinum toxin (Botox®) may be used under specialist advice, see: Torsion dystonias and other involuntary movements.

 Advise all patients starting on any acute headache treatment:
  • of the risk of developing medication-overuse headache
  • to take any acute headache treatment on no more than 2 days per week
  • to avoid opioids (including codeine and dihydrocodeine).

SUMATRIPTAN

Therapy notes

Formulation and dosage details

Formulation:

Tablets 50mgOTC, 100mg

Dosage:

By mouth, 50mg to 100mg; dose may be repeated after at least 2 hours if migraine recurs, maximum 300mg in 24 hours.
Patients unresponsive to initial dose should not take a second dose for the same attack.

Formulation and dosage details

Formulation:

Solution for injection 6mg/0.5mL

Dosage:

By subcutaneous injection, 3 to 6mg; dose may be repeated once after at least 1 hour if migraine recurs, maximum 12mg in 24 hours.
Patients unresponsive to initial dose should not take a second dose for the same attack.

Formulation and dosage details

Formulation:

Nasal spray 10mg/0.1mL unit-dose spray, 20mg/0.1mL unit-dose spray

Dosage:

Intranasally, 10mg to 20mg into one nostril; dose may be repeated once after at least 2 hours if migraine recurs; maximum 40mg in 24 hours.
Patients unresponsive to initial dose should not take a second dose for the same attack.

RIZATRIPTAN

Therapy notes

Rizatriptan is a useful alternative to sumatriptan where a more potent and rapidly acting treatment is required.  The metabolism of rizatriptan is affected by propranolol. Avoid rizatriptan completely within 2 hours of taking propranolol. At other times, patients taking propranolol should take only 5mg rizatriptan.

Formulation and dosage details

Formulation:

Tablets 5mg, 10mg

Dosage:

10mg as soon as possible after onset, repeated after 2 hours if migraine recurs. Maximum 20mg in 24 hours.
Patient not responding should not take second dose for same attack.

Formulation and dosage details

Formulation:

Orodispersible tablets 10mg

Dosage:

Orodispersible tablet: place on the tongue and allow to dissolve.
Patient not responding should not take second dose for same attack.

ZOLMITRIPTAN

Therapy notes

Formulation and dosage details

Formulation:

Tablets 2.5mg

Dosage:

By mouth, 2.5mg repeated after at least 2 hours if migraine recurs (increase to 5mg for subsequent attacks in patients not achieving satisfactory relief with 2.5mg dose); maximum 10mg in 24 hours.

Formulation and dosage details

Formulation:

Orodispersible tablets 2.5mg, 5mg

Dosage:

Orodispersible tablet: place on the tongue and allow to dissolve.

Formulation and dosage details

Formulation:

Nasal spray 5mg/0.1mL unit-dose spray

Dosage:

Intranasally: 5mg into one nostril as soon as possible after onset. repeated after at least 2 hours if migraine recurs; maximum 10mg in 24 hours.

RIMEGEPANT

Therapy notes

Formulation and dosage details

Formulation:

Oral lyophilisate 75mg (Vydura®) (Restricted: Specialist initiation only)

Initiation and review in Secondary Care. May be prescribed in Primary Care for maintenance treatment only.

Dosage:

SMC2521: For the acute treatment of migraine with or without aura in adults

SMC restriction: for patients who have had inadequate symptom relief after trials of at least two triptans or in whom triptans are contraindicated or not tolerated; and have inadequate pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.

Editorial Information

Document Id: F070