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- Look at the Treatment Tables for your particular headache- these are taken from the British Association for the Study of Headache guidelines and will help you better understand the options available
- Just show me information sheets is a shortcut to all the various information sheets
Table 3. Recommended acute treatments – simple analgesics and antiemetics
DRUG |
DOSE |
MAXIMUM DAILY DOSE |
INFORMATION |
Simple analgesics |
|||
ASPIRIN144-148 |
600-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
|
DICLOFENAC149-152 |
25 mg |
150 mg |
|
IBUPROFEN153-155 |
400-600 mg |
2400 mg |
|
KETOPROFEN156,157 |
75-150 mg |
150 mg |
|
NAPROXEN158-160 |
250 mg |
1000 mg |
|
PARACETAMOL133,161 |
1000 mg |
4000 mg |
|
TOLFENAMIC ACID162 |
200 mg |
400 mg |
|
Antiemetics |
|||
DOMPERIDONE133 |
10 mg |
30 mg |
Safety alert: MHRA-Domperidone |
PROCHLORPERAZINE163-165 |
10 mg |
30 mg |
|
METOCLOPRAMIDE132,166,167 |
10 mg |
30 mg |
Safety alert: MHRA - Metoclopramide |
Table 4. Recommended acute treatments – triptans
DRUG |
FORMULATION |
STRENGTH |
SINGLE DOSE |
MAX/24 HOURS |
ALMOTRIPTAN168,169 |
TABLET |
12.5 mg |
12.5 mg |
25 mg |
ELETRIPTAN170 |
TABLET |
40 mg |
40 mg |
80 mg |
FROVATRIPTAN171 |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
NARATRIPTAN172 |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
RIZATRIPTAN173 |
TABLET ORODISPERS LYPOPHILLISATE |
5 mg/10 mg 10 mg 10 mg |
10 mg 10 mg 10 mg |
20 mg 20 mg 20 mg |
SUMATRIPTAN137,174 |
TABLET SPRAY SUBCUT INJ |
50 mg/100 mg 100 mg/ml or 200 mg/ml 6 mg |
50-100 mg 10 - 20 mg 6 mg |
300 mg 12 mg |
ZOLMITRIPTAN175-177 |
TABLET ORODISPERS SPRAY |
2.5 mg/5 mg 2.5 mg/ 5 mg 50 mg/ml |
5 mg 5 mg 5 mg |
10 mg 10 mg 10 mg |
Table 5. Recommended preventive treatments in episodic and chronic migraine
DRUG |
START DOSE |
TITRATION |
TRIAL STUDIED DAILY DOSES |
Amitriptyline187-191 |
10-25 mg OD |
10 -25 mg |
25-150 mg |
Candesartan192,193 |
2 mg OD |
2 mg |
8-16 mg total/day |
Propranolol187,194,195 |
10 mg BD |
10-20 mg BD |
120-240 mg total/day |
Topiramate196-205 |
25 mg daily |
25 mg od |
25-200 mg total/day |
CGRP monoclonal antibodies |
|||
Erenumab206-209 |
70-140 mg monthly |
Max dose as per licensed indication |
|
Fremanezumab210 |
225 mg monthly 675 mg three-monthly |
Max dose as per licensed indication |
|
Galcanezumab211-213 |
120-240 mg monthly |
Max dose as per licensed indication |
Table 6. Recommended preventive treatments for chronic migraine only
Onabotulinumtoxin A214-218 |
155-195 IU intramuscularly, as per PREEMPT protocol |
Every 12 weeks |
Table 7. Recommended triptans for short term prevention of menstrual related migraine or pure menstrual migraine
DRUG |
FORMULATION |
STRENGTH |
FROVATRIPTAN255,256 |
TABLET |
2.5 mg twice daily on the days migraine is expected (generally from two days before until three days after bleeding starts). |
ZOLMITRIPTAN257 |
TABLET |
2.5 mg twice or three times a day on the days migraine is expected (generally from two days before until three days after bleeding starts). |
Table 8. Recommended acute treatments in tension-type headache
ANALGESIC |
SINGLE DOSE |
MAXIMUM DAILY DOSE |
Paracetamol321-323 |
1000 mg |
4000 mg |
Aspirin324,325 |
500-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
Table 9. Recommended preventive treatment in tension-type headache
DRUG |
STARTING DOSE |
TITRATION |
MAXIMUM DOSE |
Amitriptyline326-330 |
10 mg |
10-25 mg |
150 mg |
Table 10. Recommended Acute Cluster attack treatments
Treatment |
Formulation |
Strength |
Maximum Daily Dose |
Oxygen373,374 |
Inhalation through non-rebreathable mask |
7-15 L/min |
No limit |
Sumatriptan368 |
Subcutaneous injection |
6 mg |
12 mg |
Sumatriptan375 |
Nasal spray |
20 mg |
40 mg |
Zolmitriptan376-378 |
Nasal spray |
5 mg |
15 mg |
Non-invasive vagal nerve stimulation379 |
Transcutaneous |
As per specialist recommendation |
Table 11: Recommended preventive treatments for cluster headaches
Name |
Start dose |
Titration |
Max daily dose |
Comments |
Greater occipital nerve block388,389 |
Depot steroid + local anaesthetic |
Not applicable |
Not applicable |
Different formulations of steroid & anaesthetic used* |
Verapamil384 |
80 mg TDS |
Increase 80 mg every 2 weeks |
960 mg |
ECG monitoring recommended |
*There does not seem to be a difference between different local anaesthetics
Table 3. Recommended acute treatments – simple analgesics and antiemetics
DRUG |
DOSE |
MAXIMUM DAILY DOSE |
INFORMATION |
Simple analgesics |
|||
ASPIRIN144-148 |
600-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
|
DICLOFENAC149-152 |
25 mg |
150 mg |
|
IBUPROFEN153-155 |
400-600 mg |
2400 mg |
|
KETOPROFEN156,157 |
75-150 mg |
150 mg |
|
NAPROXEN158-160 |
250 mg |
1000 mg |
|
PARACETAMOL133,161 |
1000 mg |
4000 mg |
|
TOLFENAMIC ACID162 |
200 mg |
400 mg |
|
Antiemetics |
|||
DOMPERIDONE133 |
10 mg |
30 mg |
Safety alert: MHRA-Domperidone |
PROCHLORPERAZINE163-165 |
10 mg |
30 mg |
|
METOCLOPRAMIDE132,166,167 |
10 mg |
30 mg |
Safety alert: MHRA - Metoclopramide |
Table 4. Recommended acute treatments – triptans
DRUG |
FORMULATION |
STRENGTH |
SINGLE DOSE |
MAX/24 HOURS |
ALMOTRIPTAN168,169 |
TABLET |
12.5 mg |
12.5 mg |
25 mg |
ELETRIPTAN170 |
TABLET |
40 mg |
40 mg |
80 mg |
FROVATRIPTAN171 |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
NARATRIPTAN172 |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
RIZATRIPTAN173 |
TABLET ORODISPERS LYPOPHILLISATE |
5 mg/10 mg 10 mg 10 mg |
10 mg 10 mg 10 mg |
20 mg 20 mg 20 mg |
SUMATRIPTAN137,174 |
TABLET SPRAY SUBCUT INJ |
50 mg/100 mg 100 mg/ml or 200 mg/ml 6 mg |
50-100 mg 10 - 20 mg 6 mg |
300 mg 12 mg |
ZOLMITRIPTAN175-177 |
TABLET ORODISPERS SPRAY |
2.5 mg/5 mg 2.5 mg/ 5 mg 50 mg/ml |
5 mg 5 mg 5 mg |
10 mg 10 mg 10 mg |
Table 5. Recommended preventive treatments in episodic and chronic migraine
DRUG |
START DOSE |
TITRATION |
TRIAL STUDIED DAILY DOSES |
Amitriptyline187-191 |
10-25 mg OD |
10 -25 mg |
25-150 mg |
Candesartan192,193 |
2 mg OD |
2 mg |
8-16 mg total/day |
Propranolol187,194,195 |
10 mg BD |
10-20 mg BD |
120-240 mg total/day |
Topiramate196-205 |
25 mg daily |
25 mg od |
25-200 mg total/day |
CGRP monoclonal antibodies |
|||
Erenumab206-209 |
70-140 mg monthly |
Max dose as per licensed indication |
|
Fremanezumab210 |
225 mg monthly 675 mg three-monthly |
Max dose as per licensed indication |
|
Galcanezumab211-213 |
120-240 mg monthly |
Max dose as per licensed indication |
Table 6. Recommended preventive treatments for chronic migraine only
Onabotulinumtoxin A214-218 |
155-195 IU intramuscularly, as per PREEMPT protocol |
Every 12 weeks |
Table 7. Recommended triptans for short term prevention of menstrual related migraine or pure menstrual migraine
DRUG |
FORMULATION |
STRENGTH |
FROVATRIPTAN255,256 |
TABLET |
2.5 mg twice daily on the days migraine is expected (generally from two days before until three days after bleeding starts). |
ZOLMITRIPTAN257 |
TABLET |
2.5 mg twice or three times a day on the days migraine is expected (generally from two days before until three days after bleeding starts). |
Table 8. Recommended acute treatments in tension-type headache
ANALGESIC |
SINGLE DOSE |
MAXIMUM DAILY DOSE |
Paracetamol321-323 |
1000 mg |
4000 mg |
Aspirin324,325 |
500-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
Table 9. Recommended preventive treatment in tension-type headache
DRUG |
STARTING DOSE |
TITRATION |
MAXIMUM DOSE |
Amitriptyline326-330 |
10 mg |
10-25 mg |
150 mg |
Table 10. Recommended Acute Cluster attack treatments
Treatment |
Formulation |
Strength |
Maximum Daily Dose |
Oxygen373,374 |
Inhalation through non-rebreathable mask |
7-15 L/min |
No limit |
Sumatriptan368 |
Subcutaneous injection |
6 mg |
12 mg |
Sumatriptan375 |
Nasal spray |
20 mg |
40 mg |
Zolmitriptan376-378 |
Nasal spray |
5 mg |
15 mg |
Non-invasive vagal nerve stimulation379 |
Transcutaneous |
As per specialist recommendation |
Table 11: Recommended preventive treatments for cluster headaches
Name |
Start dose |
Titration |
Max daily dose |
Comments |
Greater occipital nerve block388,389 |
Depot steroid + local anaesthetic |
Not applicable |
Not applicable |
Different formulations of steroid & anaesthetic used* |
Verapamil384 |
80 mg TDS |
Increase 80 mg every 2 weeks |
960 mg |
ECG monitoring recommended |
*There does not seem to be a difference between different local anaesthetics