{"id":21625,"date":"2024-11-22T10:03:38","date_gmt":"2024-11-22T10:03:38","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=21625"},"modified":"2025-05-20T11:00:58","modified_gmt":"2025-05-20T10:00:58","slug":"migraine-chronic-headache","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/neurology\/headache\/migraine-chronic-headache\/","title":{"rendered":"Migraine\/Chronic Headache"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Nov-2024.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Migraine-in-primary-care-advice-Nov-2024.pdf<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Please note this page is designed as a summary of headache pathways (based on NHS Scotland National Headache Pathway and SIGN 155). Please consult LJF, BNF or drug Summary of Product Characteristics for contraindications, cautions, side effects, etc.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Migraine and Chronic Daily Headache<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">These recommendations apply to episodic and chronic migraine. Most patients with chronic daily headache referred to neurology have underlying chronic migraine; which often coexists with medication overuse, sleep disturbance and fatigue.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Migraine treatment can be tried in these patients as well (see leaflet on <strong><em><u>chronic daily headache at RefHelp<\/u><\/em><\/strong>).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>M.A &amp; M.M. 19-11-24<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\"><strong>Who to refer:<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients with migraine that is&nbsp;<strong>interfering with social or occupational functioning or where<\/strong>&nbsp;<strong>moderate\/severe headache days are more than 10 days a month.<\/strong><\/li>\n\n\n\n<li>Patients who&nbsp;<strong><u>have tried at&nbsp;least three first line preventative agents<\/u><\/strong>&nbsp;(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.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">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 &#8211;&nbsp;<a href=\"https:\/\/eur01.safelinks.protection.outlook.com\/?url=https%3A%2F%2Fwww.gov.uk%2Fdrug-safety-update%2Ftopiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme&amp;data=05%7C02%7CMireia.Moragas%40nhs.scot%7Cdc4510bc280a4b61603508dd03fcb74e%7C10efe0bda0304bca809cb5e6745e499a%7C0%7C0%7C638671106139863940%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&amp;sdata=9pjEkKz5CUBLUBdHy%2FH9YNIsAZ%2BfKCCViW9x4mM2hEs%3D&amp;reserved=0\" target=\"_blank\" rel=\"noreferrer noopener\">Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme &#8211; GOV.UK (www.gov.uk)<\/a>&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>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.<\/strong>&nbsp;Responses may happen after 3 months of treatment, so it is recommended to keep for 4-6 months if tolerated, before assessment.\n<ul class=\"wp-block-list\">\n<li><strong>Atogepant 60mg daily<\/strong>&nbsp;<strong>may be prescribed&nbsp;for episodic or chronic migraine<\/strong>&nbsp;in primary care&nbsp;if patients have more than 10 &nbsp;moderate\/severe migraine days per month and have not responded to three preventative agents &nbsp;(tricyclic, propranolol, candesartan).&nbsp;<\/li>\n\n\n\n<li><strong>Rimegepant 75mg every other day<\/strong>&nbsp;<strong>may be prescribed as&nbsp;preventative&nbsp;for episodic migraine<\/strong>&nbsp;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).<\/li>\n\n\n\n<li><strong>Rimegepant 75mg once daily may also be prescribed as acute treatment<\/strong> in primary care &#8211; no more than 10 times a month &#8211; 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.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Who not to refer:<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Patients with episodic migraine which is not interfering with social or occupational functioning and in whom further preventatives are not indicated.<\/li>\n\n\n\n<li>Patients who have not been through the acute treatment and at least three preventative agents (tricyclic, topiramate&nbsp;(except women in childbearing age),&nbsp;propranolol, candesartan).<\/li>\n\n\n\n<li>Patients with clear medication overuse headache where that has not been addressed yet.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><em>Information on eligibility for Botulinum Toxin, injectable CGRP drugs (eg Erenumab, Fremanezumab, Galcanezumab):<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients may be eligible for Botulinum Toxin&nbsp;or CGRP medications&nbsp;if they meet the criteria for \u2018who to refer\u2019 listed above, dependent on an assessment in the headache clinic.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\"><strong>General Lifestyle Advice<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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&nbsp;<a href=\"http:\/\/www.migrainetrust.org\/\" target=\"_blank\" rel=\"noreferrer noopener\"><strong><em>The Migraine Trust<\/em><\/strong><\/a>&nbsp;or the&nbsp;<a href=\"http:\/\/www.headachereliefguide.com\/\" target=\"_blank\" rel=\"noreferrer noopener\"><strong><em>Headache Relief Guide<\/em><\/strong><\/a><strong>&nbsp;\u2013&nbsp;<\/strong>(interactive tools built for teenagers but good for adults too). Sleep management (prescribe \u2018<em><u><a href=\"https:\/\/www.nhsinform.scot\/waiting-well\/support-your-health-and-wellbeing-while-you-wait\/sleep\/#:~:text=Sleepio%20is%20a%20digital%20sleep,to%2020%20minute%20CBT%20sessions.\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Sleepio<\/strong><\/a><\/u><\/em>\u2019 app for free in NHS Scotland), aerobic exercise and psych therapies help some.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Acute Treatments\u2013 have you provided adequate trials of different acute treatments?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">All acute treatments work better if combined with sleep where possible<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Acute treatments&nbsp;<strong>should be taken no more than 10 times a month<\/strong>&nbsp;to avoid medication overuse headache<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\"><table class=\"has-light-accent-blue-background-color has-background has-fixed-layout\"><tbody><tr><td><strong>Mild to moderate<\/strong><\/td><td><strong>Moderate to severe<\/strong><\/td><td><strong>Add antiemetic if significant nausea<\/strong><\/td><\/tr><tr><td>Paracetamol 1000mg<\/td><td>Sumatriptan 50-100mg &nbsp;<\/td><td>Prochlorperazine 10mg (also has an analgesic effect)<\/td><\/tr><tr><td>Aspirin 900mg<\/td><td>Try other formulary triptans if Sumatriptan ineffective: Almotriptan, Rizatriptan or Frovatriptan (longer half-life).<\/td><td>Metoclopramide 10mg (prokinetic effects useful)<\/td><\/tr><tr><td>Ibuprofen 400-600mg<\/td><td>Consider other routes of administration if significant nausea or vomiting, <em>i.e. <\/em>nasal Zolmitriptan 5mg, subcut Sumatriptan 6mg<\/td><td rowspan=\"2\">Antiemetics should be used short term to reduce risk of side effects<\/td><\/tr><tr><td>Naproxen 500mg<\/td><td>Rimegepant 75mg daily can be considered for patients not responding to \u22652 triptans, or if triptans contraindicated<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">Avoid opioids \u2013 less effective and significant risk of medication overuse headache.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Any triptan can be used in combination with NSAID or Aspirin, if triptan alone does not give sufficient relief.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Prophylaxis \u2013 have you provided adequate trials of different prophylactic treatments?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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&nbsp;<strong>reduce the frequency and\/or severity<\/strong>&nbsp;of attacks, not abolish them completely; a reduction of 30% in either frequency or severity is a positive response.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients should be warned to expect some side effects, particularly initially, and&nbsp;<strong>use each treatment for at least 8 weeks after reaching maximal tolerable dose,&nbsp;<\/strong>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.<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\"><table class=\"has-light-accent-blue-background-color has-background has-fixed-layout\"><tbody><tr><td><strong>Medication<\/strong><\/td><td><strong>Amitriptyline<\/strong><\/td><td><strong>Candesartan<\/strong><\/td><td><strong>Propranolol<\/strong><\/td><td><strong>Topiramate<\/strong><mark style=\"background-color:#E6EDF1\" class=\"has-inline-color has-alert-red-color\">*<\/mark><\/td><\/tr><tr><td>Starting dose<\/td><td>10mg nocte If excess drowsiness, try a less sedating tricyclic <em>e.g.<\/em> Nortriptyline<\/td><td>2-4mg OD Check baseline Cr&amp;E<\/td><td>10-20mg BD<\/td><td>25mg nocte <strong>&nbsp;NB: Contraindicated in women of childbearing potential unless pregnancy prevention programme in place<\/strong><\/td><\/tr><tr><td>Suggested increment<\/td><td>10mg every 1-2 weeks &nbsp;<\/td><td>2-4mg every 1-2 weeks Check Cr&amp;E intermittently<\/td><td>10-20mg BD every 1-2 weeks<\/td><td>25mg every 1-2 weeks<\/td><\/tr><tr><td>Target dose (or highest tolerated)<\/td><td>50mg nocte If partially effective and well tolerated, further up titration possible to 100mg<\/td><td>16mg OD (or 8mg BD)<\/td><td>80mg BD<\/td><td>50mg BD If partially effective and well tolerated, further up titration possible to 100mg BD<\/td><\/tr><\/tbody><\/table><figcaption class=\"wp-element-caption\"><em><mark style=\"background-color:#ffffff\" class=\"has-inline-color has-alert-red-color\">*Please also refer to\u00a0 <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/sexualreprohealth\/contraception\/topiramate-contraception\/\">Topiramate &amp; Contraception \u2013 RefHelp<\/a><\/mark><\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Gepants:<\/strong> can be prescribed&nbsp;for prevention of episodic or chronic migraine in primary care&nbsp;if patients have more than 10 moderate\/severe migraine days per month and have not responded to three preventative agents.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Atogepant<\/strong> 60mg daily: &nbsp;for episodic or chronic migraine. <strong>Rimegepant<\/strong> 75mg every other day: for episodic migraine.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Botox and CGRP medications<\/strong> (e.g. Erenumab, Fremanezumab, Galcanezumab) <strong>are available for eligible patients on prescription or recommendation from the Headache clinics run in Neurology.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/neurology\/headache\/migraine-chronic-headache-in-pregnancy\/\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Prenancy&nbsp;<\/strong><\/a>: 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Open access CT brain scan:<\/strong>&nbsp;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.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\">National Headache Pathway:&nbsp;<a href=\"https:\/\/eur01.safelinks.protection.outlook.com\/?url=https%3A%2F%2Fwww.nhscfsd.co.uk%2Four-work%2Fmodernising-patient-pathways%2Fspecialty-delivery-groups%2Fneurology%2Fnational-headache-pathway%2F&amp;data=05%7C02%7Cmohammed.alshaikly%40nhs.scot%7C77613dd110b242b7e09b08dc6f7ad26b%7C10efe0bda0304bca809cb5e6745e499a%7C0%7C0%7C638507821837311686%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&amp;sdata=6oe2n8aN58Tednz4%2FfGY5soxYpG2MLOfh8Z7%2Fi7%2BQmM%3D&amp;reserved=0\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nhscfsd.co.uk\/our-work\/modernising-patient-pathways\/specialty-delivery-groups\/neurology\/national-headache-pathway\/<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">NHS Lothian Joint Formulary:&nbsp;<a href=\"https:\/\/formulary.nhs.scot\/east\/central-nervous-system\/pain-related-conditions\/migraine\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/formulary.nhs.scot\/east\/central-nervous-system\/pain-related-conditions\/migraine\/<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The Migraine Trust\u201d \u2013&nbsp;<a href=\"https:\/\/eur01.safelinks.protection.outlook.com\/?url=http%3A%2F%2Fwww.migrainetrust.org%2F&amp;data=05%7C02%7Cmohammed.alshaikly%40nhs.scot%7C77613dd110b242b7e09b08dc6f7ad26b%7C10efe0bda0304bca809cb5e6745e499a%7C0%7C0%7C638507821837334583%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&amp;sdata=IjcVvRRNC4GPAY2iGPdsK35k5rvk72efPtEAoBO3UIg%3D&amp;reserved=0\" target=\"_blank\" rel=\"noreferrer noopener\">www.migrainetrust.org<\/a>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/eur01.safelinks.protection.outlook.com\/?url=http%3A%2F%2Fwww.headachereliefguide.com%2F&amp;data=05%7C02%7Cmohammed.alshaikly%40nhs.scot%7C77613dd110b242b7e09b08dc6f7ad26b%7C10efe0bda0304bca809cb5e6745e499a%7C0%7C0%7C638507821837341191%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&amp;sdata=MYs8CrHBgH3vQcmME25MJlwV6Aok14JCsmKWFAZVvjo%3D&amp;reserved=0\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.headachereliefguide.com<\/a>&nbsp;<em>(interactive tools built for teenagers but good for adults too). Aerobic exercise, regular sleep helps some.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/Migraine-in-primary-care-advice-Nov-2024.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Migraine-in-primary-care-advice-Nov-2024.pdf<\/a><\/p>\n<\/div><\/div>\n<\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Migraine-in-primary-care-advice-Nov-2024.pdf Please note this page is designed as a summary of headache pathways (based on NHS Scotland National Headache Pathway and SIGN 155). Please consult LJF, BNF or drug Summary of Product Characteristics for contraindications, cautions, side effects, etc. Migraine and Chronic Daily Headache These recommendations apply to episodic and chronic migraine. Most patients with<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":3989,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[1188],"class_list":["post-21625","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-migraine-chronic-headache"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/neurology\/headache\/https-apps-nhslothian-scot-refhelp-migraine-chronic-headache\/\" rel=\"tag\">Migraine\/Chronic Headache<\/a>","rttpg_excerpt":"Migraine-in-primary-care-advice-Nov-2024.pdf Please note this page is designed as a summary of headache pathways (based on NHS Scotland National Headache Pathway and SIGN 155). Please consult LJF, BNF or drug Summary of Product Characteristics for contraindications, cautions, side effects, etc. Migraine and Chronic Daily Headache These recommendations apply to episodic and chronic migraine. Most patients with","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21625","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=21625"}],"version-history":[{"count":9,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21625\/revisions"}],"predecessor-version":[{"id":24092,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/21625\/revisions\/24092"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/3989"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=21625"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=21625"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}