Migraine/Chronic headache

 Who to refer:

1. Patients with migraine that is interfering with social or occupational functioning or where moderate/severe headache days are more than 10 days a month.
2. Patients who have tried at least three first line preventative agents (tricyclic, topiramate, propranolol, candesartan). When using preventative treatment migraine ensure medication has been tried at a therapeutic dose (if tolerated) for 8 weeks each expecting a reduction of migraine. There is no medication that abolishes migraine.

Topiramate should not be given in women in childbearing age, and it is no longer a requirement before referral/advanced therapies for this population group. If it is prescribed to women of childbearing age then you need to follow the Pregnancy Prevention Programme procedure – Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme – GOV.UK (www.gov.uk) 

3. Patients who have not responded to at least three first line preventive treatment may be started on gepants (Atogepant/Rimegepant) prior to referral to secondary care. Responses may happen after 3 months of treatment, so it is recommended to keep for 4-6 months if tolerated, before assessment.

• • Atogepant 60mg daily may be prescribed for episodic or chronic migraine in primary care if patients have more than 10  moderate/severe migraine days per month and have not responded to three preventative agents  (tricyclic, propranolol, candesartan). 
  • Rimegepant 75mg every other day may be prescribed as preventative for episodic migraine in primary care if patients have 10 to 14 moderate/severe migraine days per month and have not responded to three preventative agents (tricyclic, propranolol, candesartan).
  • Rimegepant 75mg once daily may also be prescribed as acute treatment in primary care – no more than 10 times a month – for patients who have not responded to adequate trials of at least 2 triptans or triptans are contraindicated. At the moment combination of two different gepants is not recommended.

How to refer:

via the ‘Chronic Headache’ pathway on SCI gateway (RIE> Neurology> LI Chronic Headache)

General Lifestyle Advice

Common triggers: Sleep deprivation/excess, missing meals, exercise, stress (too much or relaxing after stress), minor neck/head injury, menstruation, alcohol. Useful advice available at The Migraine Trust or the Headache Relief Guide – (interactive tools built for teenagers but good for adults too). Sleep management (prescribe ‘Sleepio’ app for free in NHS Scotland), aerobic exercise and psych therapies help some.

Acute Treatments– have you provided adequate trials of different acute treatments?

All acute treatments work better if combined with sleep where possible

Acute treatments should be taken no more than 10 times a month to avoid medication overuse headache

Mild to moderate	Moderate to severe	Add antiemetic if significant nausea
Paracetamol 1000mg	Sumatriptan 50-100mg	Prochlorperazine 10mg (also has an analgesic effect)
Aspirin 900mg	Try other formulary triptans if Sumatriptan ineffective: Almotriptan, Rizatriptan or Frovatriptan (longer half-life).	Metoclopramide 10mg (prokinetic effects useful)
Ibuprofen 400-600mg	Consider other routes of administration if significant nausea or vomiting, i.e. nasal Zolmitriptan 5mg, subcut Sumatriptan 6mg	Antiemetics should be used for short term use to reduce risks of side effects
Naproxen 500mg	Rimegepant 75mg daily can be considered for patients not responding to ≥2 triptans, or if triptans contraindicated

Avoid opioids – less effective and significant risk of medication overuse headache.

Any triptan can be used in combination with NSAID or Aspirin, if triptan alone does not give sufficient relief.

Prophylaxis – have you provided adequate trials of different prophylactic treatments?

Prophylaxis should be considered when patients are overusing acute treatments, or headaches interfere with social or occupational functioning. Patients must be counselled that prophylaxis aims to reduce the frequency and/or severity of attacks, not abolish them completely; a reduction of 30% in either frequency or severity is a positive response. 

Patients should be warned to expect some side effects, particularly initially, and use each treatment for at least 8 weeks after reaching maximal tolerable dose, before deciding if a treatment is effective; avoid discontinuation of tolerable prophylaxis prior to this point. Slower titrations may improve tolerability, and some more minor side effects may improve after a period of dose stability.

Medication	Amitriptyline	Candesartan	Propranolol	Topiramate
Starting dose	10mg nocte If excess drowsiness, try a less sedating tricyclic e.g. Nortriptyline	2-4mg OD Check baseline Cr&E	10-20mg BD	25mg nocte NB: Contraindicated in women of childbearing potential unless pregnancy prevention programme in place
Suggested increment	10mg every 1-2 weeks	2-4mg every 1-2 weeks Check Cr&E intermittently	10-20mg BD every 1-2 weeks	25mg every 1-2 weeks
Target dose (or highest tolerated)	50mg nocte If partially effective and well tolerated, further up titration possible to 100mg	16mg OD (or 8mg BD)	80mg BD	50mg BD If partially effective and well tolerated, further up titration possible to 100mg BD

Gepants: can be prescribed for prevention of episodic or chronic migraine in primary care if patients have more than 10 moderate/severe migraine days per month and have not responded to three preventative agents.

Atogepant 60mg daily:  for episodic or chronic migraine. Rimegepant 75mg every other day: for episodic migraine.

Botox and CGRP monoclonal antibody drugs (erenumab, fremanezumab and galcanezumab) are available for eligible patients who are referred to secondary care headache clinics.

Pregnancy: Migraine will often improve during pregnancy, but not for all patients. Maximise lifestyle advice. See separate RefHelp page for guidance on therapies for management. Most migraine treatments require caution, or are contraindicated, in pregnancy.

Open access CT brain scan: NHS Lothian offers open access CT head scan. Evidence suggests that CT head has no long-lasting reassuring effect in patients worried about their headache. Consider the 10% rate of incidental findings, negligible chance of a relevant finding in a patient with migraine, radiation dose and resource implications of a CT head scan.

National Headache Pathway: https://www.nhscfsd.co.uk/our-work/modernising-patient-pathways/specialty-delivery-groups/neurology/national-headache-pathway/

NHS Lothian Joint Formulary: https://formulary.nhs.scot/east/central-nervous-system/pain-related-conditions/migraine/

The Migraine Trust” – www.migrainetrust.org. 

http://www.headachereliefguide.com (interactive tools built for teenagers but good for adults too). Aerobic exercise, regular sleep helps some.

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