Acute Migraine
Recommended acute treatments – simple analgesics and antiemetics
|
DRUG |
DOSE |
MAXIMUM DAILY DOSE |
INFORMATION |
|
Simple analgesics |
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|
ASPIRIN |
600-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
|
|
DICLOFENAC |
25 mg |
150 mg |
|
|
IBUPROFEN |
400-600 mg |
2400 mg |
|
|
KETOPROFEN |
75-150 mg |
150 mg |
|
|
NAPROXEN |
250 mg |
1000 mg |
|
|
PARACETAMOL |
1000 mg |
4000 mg |
|
|
TOLFENAMIC ACID |
200 mg |
400 mg |
|
|
Antiemetics |
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|
DOMPERIDONE |
10 mg |
30 mg |
Safety alert: MHRA-Domperidone |
|
PROCHLORPERAZINE |
10 mg |
30 mg |
|
|
METOCLOPRAMIDE |
10 mg |
30 mg |
Safety alert: MHRA – Metoclopramide |
Recommended acute treatments – triptans
|
DRUG |
FORMULATION |
STRENGTH |
SINGLE DOSE |
MAX/24 HOURS |
|
ALMOTRIPTAN |
TABLET |
12.5 mg |
12.5 mg |
25 mg |
|
ELETRIPTAN |
TABLET |
40 mg |
40 mg |
80 mg |
|
FROVATRIPTAN |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
|
NARATRIPTAN |
TABLET |
2.5 mg |
2.5 mg |
5 mg |
|
RIZATRIPTAN |
TABLET ORODISPERS LYPOPHILLISATE |
5 mg/10 mg 10 mg 10 mg |
10 mg 10 mg 10 mg |
20 mg 20 mg 20 mg |
|
SUMATRIPTAN |
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 |
|
ZOLMITRIPTAN |
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 |
Migraine Prevention
Recommended preventive treatments in episodic and chronic migraine
|
DRUG |
START DOSE |
TITRATION |
TRIAL STUDIED DAILY DOSES |
|
Amitriptyline |
10-25 mg OD |
10 -25 mg |
25-150 mg |
|
Candesartan |
2 mg OD |
2 mg |
8-16 mg total/day |
|
Propranolol |
10 mg BD |
10-20 mg BD |
120-240 mg total/day |
|
Topiramate |
25 mg daily |
25 mg od |
25-200 mg total/day |
|
CGRP monoclonal antibodies |
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|
Erenumab |
70-140 mg monthly |
Max dose as per licensed indication |
|
|
Fremanezumab |
225 mg monthly 675 mg three-monthly |
Max dose as per licensed indication |
|
|
Galcanezumab |
120-240 mg monthly |
Max dose as per licensed indication |
Since the publication of the BASH guideline in 2019, the UK National Institute for Clinical Excellence has published Technology Appraisals for several new preventative treatments for episodic and chronic migraine. Fremenezumab [TA764], Erenumab [TA682] and Galcanezumab [TA659] and Eptinezumab [TA871] should now be available to eligible patients in England & Wales if their treating doctor believes it is the most appropriate treatment for them. Rimegepant [TA919] is available for use in episodic migraine (4-14 attacks per month), taking into account available options and price. See the NICE website for the most up to date information.
Recommended preventive treatments for chronic migraine only
|
Onabotulinumtoxin A |
155-195 IU intramuscularly, as per PREEMPT protocol |
Every 12 weeks |
Menstrual Migraine
Recommended triptans for short term prevention of menstrual related migraine or pure menstrual migraine
|
DRUG |
FORMULATION |
STRENGTH |
|
FROVATRIPTAN |
TABLET |
2.5 mg twice daily on the days migraine is expected (generally from two days before until three days after bleeding starts). |
|
ZOLMITRIPTAN |
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). |
Tension Type Headache
Recommended acute treatments in tension-type headache
|
ANALGESIC |
SINGLE DOSE |
MAXIMUM DAILY DOSE |
|
Paracetamol |
1000 mg |
4000 mg |
|
Aspirin |
500-1000 mg (UK doses are 300-900 mg) |
4000 mg (for oral dosing) |
Recommended preventive treatment in tension-type headache
|
DRUG |
STARTING DOSE |
TITRATION |
MAXIMUM DOSE |
|
Amitriptyline |
10 mg |
10-25 mg |
150 mg |
Cluster Headache
Recommended Acute Cluster attack treatments
|
Treatment |
Formulation |
Strength |
Maximum Daily Dose |
|
Oxygen |
Inhalation through non-rebreathable mask |
7-15 L/min |
No limit |
|
Sumatriptan |
Subcutaneous injection |
6 mg |
12 mg |
|
Sumatriptan |
Nasal spray |
20 mg |
40 mg |
|
Zolmitriptan |
Nasal spray |
5 mg |
15 mg |
|
Non-invasive vagal nerve stimulation |
Transcutaneous |
As per specialist recommendation |
Recommended preventive treatments for cluster headaches
|
Name |
Start dose |
Titration |
Max daily dose |
Comments |
|
Greater occipital nerve block |
Depot steroid + local anaesthetic |
Not applicable |
Not applicable |
Different formulations of steroid & anaesthetic used* |
|
Verapamil |
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