Migraine Info for Sufferers

Recommended acute treatments – simple analgesics and antiemetics

DRUG	DOSE	MAXIMUM DAILY DOSE	INFORMATION
Simple analgesics
ASPIRIN^144-148	600-1000 mg (UK doses are 300-900 mg)	4000 mg (for oral dosing)
DICLOFENAC^149-152	25 mg	150 mg
IBUPROFEN^153-155	400-600 mg	2400 mg
KETOPROFEN^156,157	75-150 mg	150 mg
NAPROXEN^158-160	250 mg	1000 mg
PARACETAMOL^133,161	1000 mg	4000 mg
TOLFENAMIC ACID¹⁶²	200 mg	400 mg
Antiemetics
DOMPERIDONE¹³³	10 mg	30 mg	Safety alert: MHRA-Domperidone
PROCHLORPERAZINE^163-165	10 mg	30 mg
METOCLOPRAMIDE^132,166,167	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

NICE has published a technology appraisal [TA919] – available here – appropriate when triptans are contraindicated or when trial of 2 triptans has not been sufficiently effective.

Recommended preventive treatments in episodic and chronic migraine

The UK Medications and Healthcare Products Regulatory Agency (MHRA) has begun a review into the safety of topiramate, which will look at possible harms in the learning and development of children whose mothers took topiramate during pregnancy.

At present, it is recommended that anyone of child bearing potential should use highly effective contraception and avoid pregnancy while taking topiramate. You should review the MRHA website regularly to remain aware of the latest advice.

If you have concerns about your use of topiramate in the light of this development, please talk to your prescribing physician.

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
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

Recommended triptans for short term prevention of menstrual related migraine or pure menstrual migraine

DRUG	FORMULATION	STRENGTH
FROVATRIPTAN^255,256	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).