Acute GP service

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).

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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.

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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).

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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.