Migraine/Chronic Headache – advice for primary care management
Richard Davenport and Jon Stone. Dept Clinical Neurosciences, NHS Lothian. January 2021
Please note this is only designed as a brief summary of headache pathway (based on SIGN 155 and BASH Guideline- sign.ac.uk, bash.org.uk). Please consult BNF for contraindications, cautions, side effects. More information at www.refhelp.scot.nhs.uk/
Migraine and Chronic Daily Headache
These recommendations apply primarily to episodic migraine. Most patients with chronic daily headache referred to neurology have underlying chronic migraine, typically in association with medication overuse, sleep disturbance and fatigue. Migraine treatment can be tried in these patients as well (see leaflet on chronic daily headache at Refhelp). Chronic daily headache may benefit from attention paid to factors exacerbating sleep and fatigue issues.
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” – www.migrainetrust.org and www.headachereliefguide.com (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.
Download PDF form Migraine/Chronic Headache – advice for primary care management
Who to refer:
Failure of primary care management as outlined in the corresponding pages.
When using preventative treatment migraine ensure medication has been tried at a therapeutic dose for 3-4 months each
Who not to refer:
- Patients who have not been through the acute treatment and at least three preventative agents listed below
- Patients with clear medication overuse headache where that has not been addressed yet
- Patients with episodic migraine which is not interfering with social or occupational functioning and in whom further preventatives are not indicated.
How to refer:
Sci-gateway RIE> Neurology
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
| First Line If nausea | Aspirin 600-900mg up to 4 doses in 24 hours Ibuprofen 400-600mg up to 4 doses in 24 hours Cyclizine 50mg up to 3 doses in 24 hours |
| Second line – Triptans Patients may respond to one triptan when another has failed. Try a different route. Generally use no more than two doses in 24 hours. Repeated use leads to analgesic headache | Almotriptan 12.5mg (probably most cost effective) Eletriptan 40mg or 80mg (fast acting) Rizatriptan 10mg (melt in the mouth wafer) Sumatriptan injection 6mg may be better than any oral preparation |
Paracetamol is only recommended for mild to moderate intensity of migraine. Avoid Codeine / Dihydrocodeine or any combination with opioids, they are not as helpful as triptans and can lead easily to medication overuse.
Prophylaxis – have you provided adequate trials of different prophylactic treatments?
Prophylaxis should be considered when patients are overusing acute treatments or have headaches interfering with social and occupational functioning. Patients must be counselled that prophylaxis aims to reduce the frequency and severity of attacks, not abolish them. Patients should be told to expect side effects initially and use each treatment for at least 3 months. Often the reason for ineffectiveness is lack of perseverance or medication overuse.
| Beta Blockers | Propranolol 80mg od-160mg bd (Modified Release formulations). Atenolol 25-100mg od alternative | |
| Tricyclics | Amitriptyline* 10mg daily aiming for 75mg, at or 1-2 hours before bedtime, is first-line when migraine coexists with: tension-type headache; another chronic pain condition; disturbed sleep; depression. To be increased by 10mg every 2-4 weeks if needed and tolerated. Nortriptyline is less sedative. | |
| Anticonvulsants | Topiramate 25mg once daily increasing by 25mg every week aiming for 50mg bd or 100mg bd as reqd Females need to be advised of OCP interaction and risks to the foetus of conceiving on this drug Sodium Valproate 400-1500mg daily can be considered only for men or women over 55 (always consult latest MHRA guidance for use of valproate). | |
| Others (limited evidence) | Candesartan* 8mg daily increasing to 16mg Pizotifen 0.5-1.5mg –may cause weight gain | Riboflavin 400mg once daily is mentioned in NICE but not SIGN guideline; Magnesium, Feverfew and Melatonin are not mentioned in either |
| Only available via Neurology | Botulinum Toxin CGRP pathway drugs (eg Erenumab) | For treatment resistant chronic migraine meeting eligibility criteria |
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.
