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Migraine - Primary care adult management

Dr E Deeks 24/3/24

Diagnostic criteria :
  • Exclude secondary headaches. See NICE for further details and a list of red flags needing immediate action.

  • Recurrent headache disorder (5 or more lifetime headache attacks), manifesting in attacks lasting 4-72 hours (untreated or unsuccessfully treated).

  • Typical characteristics of the headache are (at least two or more): unilateral location; pulsating quality; moderate or severe pain intensity; aggravation by routine physical activity and association with (at least one): nausea/vomiting and photo/phonophobia

  • Aura: 25% of migraineurs experience aura (for at least some of their attacks). Recurrent attacks (more than 2), lasting minutes, of unilateral fully-reversible visual, sensory or other central nervous system symptoms that usually develop gradually and followed by headache and associated migraine symptoms.

  • Chronic migraine: Headache 15 days/month of which ≥8 have migraine features (for more than 3 months)

Acute treatment :

Offer combination therapy (See NICE and BASH (p.23-26) for further guidance):

1st: simple analgesia + prokinetic antiemetic (do not prescribe opioids e.g. Co-codamol).

2nd: Triptans + simple analgesia + prokinetic antiemetic

Three different triptans should each be trialled on a minimum of two separate occasions, in line with the CIoS Joint Medicines Formulary, before determining whether patient is a triptan non-responder. Triptans should not be taken on ≥10 days/month and simple analgesia on ≥15 days/month to avoid medication overuse headache (also see section below).

Triptan guidance:
  1. The below should be used in patients naïve to triptans or needing an alternative, do not amend existing prescriptions if effective and well tolerated. The below should be read in conjunction with the medications SmPC and the CIoS Joint Medicines Formulary, please consider possible interactions. The safety of triptans in patients in older than 65 years has not been systematically evaluated and if possible, should be avoided. Contraindications include ischaemic heart disease, cerebrovascular disease, previous myocardial infarction and uncontrolled hypertension. Specialist advice can be obtained via Advice & Guidance (A&G) or referring to specialist headache services.

  2. Triptans are used as an acute treatment of a migraine attack, most effective when taken early in the headache phase of an attack (see BASH for further info). Generally, if a patient has responded to the first dose of a triptan, but symptoms recur a second dose may be given, with a minimum 2-hour interval, not exceeding maximum dose in 24 hours. If the patient does not respond to the first dose of a triptan, a second dose is not advised for the same attack.

  3. It is advisable that a patient tries a triptan on a minimum of 2 separate occasions prior to determining their response and should try three different triptans prior to determining patient is a triptan non-responder.

  4. Headache recurrence refers to patients who consistently have a significant response to a triptan, but the headache rebounds or recurs and therefore a longer-lasting triptan may be more suitable to provide a more sustained response.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other considerations:

Sumatriptan nasal spray has poor absorption and an unpleasant taste therefore has not been included in the above. However, it is the only licensed triptan for 12–18-year-olds (outside scope of this guide).

Failure of first-line reliever medicine strategies

If a patient fails 2 different triptans (or cannot tolerate triptans or triptans are contraindicated) NICE has now licensed Rimegepant for use in these patients- and this can be initiated by the GP in Cornwall for treatment for acute migraine. The main contraindications to rimegepant are:

  • eGFR <15,

  • severe liver failure,

  • pregnancy,

  • breastfeeding

It is only licensed in those 18 or over. For more information on interactions and cautions please see the BNF website. Unlike triptans and conventional analgesia there is currently no evidence that it causes medication overuse headache. NB this is a different indication for its use than as a preventer, see below section.

Preventative treatment :

Consider a preventative treatment for patients if they:

  • are taking analgesics for 2 or more days per week OR experience migraine symptoms on more than 4-5 days per month (for more than 3 months)

  • experience less than 4-5 migraine days per month, but with poor response to acute treatment

  • cannot take suitable acute treatment for migraine attacks due to contraindications or intolerance

 

Please consider when choosing a preventative treatment from the list below: patients past medical history, co-morbidities (including depression/anxiety/suicidal ideation), and whether they have child-bearing potential. The order in which the treatments are chosen should be individualised to the patient based on the above. Side-effects are common with these medications, but often improve over time, please encourage patients to titrate the medication as tolerated/required (see BASH (page 28-29) for further guidance) and to take at least the target dose for a minimum of 3 months before determining effectiveness. We suggest reviewing treatment every six months. If effective consider tapering the dose after 6-12 months and advise patient to monitor for deterioration.

Preventative medication: each for low start and slow uptitration in accordance to BNF

 

Amitriptyline - special considerations: See SmPC - Do not exceed 1mg/kg If unable to tolerate low dose amitriptyline consider nortriptyline (SmPC) with the same dosing guidance.

Propranolol - See SmPC Consider switching to a long-acting formulation once a maintenance dose is achieved.

Topiramate - On specialist advice only (consider using Advice & Guidance) See SmPC and MHRA advice on antiepileptic drugs in pregnancy – Not recommended in pregnancy and breastfeeding, ensure highly effective contraception.

Candesartan - See SmPC - Not recommended in pregnancy and caution in breastfeeding, ensure highly effective contraception. U&Es at baseline, three months and once yearly

Frovatriptan or zolmitriptan tablets should be considered (after NSAIDs) as preventative treatment for menstrual migraine: on the day's migraine is expected, generally from 2 days before until 3 days after (only suitable if cycle is regular/predictable). See NICE and BASH for further details.

Rimegepant (Vydura) for episodic migraine (4-15 per month) as per NICE guidance. Dosing is alternate days for this indication, however episodic prevention is amber on the formulary at present so can only be initiated for this reason after advice and guidance from the neurology department. [NB. Rimegepant can also be used as an acute headache reliever in triptan non-response (see below under failure of acute migraine strategies).

Medication overuse headache

When prescribing for migraine or headache please consider medication overuse headache (MOH).

Please ensure patients are taking paracetamol and nsaids for less than <15 days per month.

Please ensure patients are taking ergotamine, triptans or opioids as well as combination painkillers for less than <10 days per month.

In the event that patients are potentially suffering from MOH the advice is to stop or reduce this medication while introducing a preventative medication. Please warn patients that initially the headaches may get worse or more frequent, but that in time the headaches will improve.

Referrals:

Refer to a specialist headache service for advice and consideration of further treatment when patients have failed 3 different preventers  (or these preventers are contraindicated, or patient cannot tolerate them due to side effects)  for episodic (4-15 headache days a month) or chronic migraine (over 15 headache days a month with at least 8 of those having features of migraine).

 

Please ensure patients complete a headache diary prior to referral as in order to fulfil the funding criteria, there must be evidence of headache frequency.

 

Secondary care treatment options include regular Rimegepant as a preventer, anti-CGRP inhibitors or botulinum toxin. We ask patients to complete headache diaries once they have started treatment as its effectiveness needs to be documented in order to maintain treatment funding.

Specialist advice can also be obtained via Advice & Guidance (A&G).

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