Acute therapy

Pharmacological management of migraine (SIGN)
Healthcare Improvement Scotland

Avoid opiates and restrict acute medication to 2 days a week.

Good practice point tickWhen starting acute treatment healthcare professionals should warn patients about the risk of developing medication-overuse headache.

First-line therapies

RecommendationAspirin 900 mg

RecommendationIbuprofen 400–600 mg

RecommendationTriptans:

  • Sumatriptan 50–100 mg is first choice
  • Oral triptans are gastrically absorbed, so may not work if the patient is vomiting
  • Triptans only work once headache starts
  • Generally effective in 2 out of 3 attacks,

Good practice point tick symbol Triptans should not be used in patients at high risk of ischaemic cardiovascular disease, including
uncontrolled hypertension.

RecommendationParacetamol (1,000 mg) can be considered in those unable to take other therapies.

Early or persistent vomiting?

Recommendation Metoclopramide 10 mg or prochloperazine 10 mg. Either an oral or parenteral formulation can be used.

Good practice point tick symbolMetaclopramide should not be used regularly due to the risk of extrapyramidal side effects.

RecommendationConsider nasal zolmitriptan or subcutaneous sumatriptan.

 

Second-line therapy

RecommendationTriptans other than sumatriptan.

RecommendationConsider coprescription of sumatriptan (50–85 mg) and naproxen (500 mg).

The dose for sumatriptan corresponds to the doses used in the clinical trials. In the UK sumatriptan is available and used in 50 mg and 100 mg doses. 

Good practice point tick symbol Consider a combination of a triptan with a non-steroidal agent and/or an antiemetic.

Good practice point tick symbol Triptans should not be used in patients at high risk of ischaemic cardiovascular disease, including
uncontrolled hypertension.

Recommendation Consider rimegepant for patients who have contraindications to triptans.

Good practice point tick symbol Careful consideration should be given to the potential risks and benefits for patients at high risk of
ischaemic cardiovascular disease, including uncontrolled hypertension, before prescribing oral CGRP
receptor antagonists.

Third-line therapy

Recommendation Consider rimegepant for patients who have had an inadequate response or poor tolerability to two or more triptans, and paracetamol or NSAIDS are ineffective or unsuitable.

Good practice point tick symbol Careful consideration should be given to the potential risks and benefits for patients at high risk of
ischaemic cardiovascular disease, including uncontrolled hypertension, before prescribing oral CGRP
receptor antagonists.

Therapies during pregnancy

Good practice point tickDue to its safety profile, paracetamol is first choice for the short-term relief of mild-to-moderate headache during any trimester of pregnancy.

Recommendation Consider sumatriptan in all stages of pregnancy. The risk associated with use should be discussed before commencing treatment.

Good practice point tickAspirin, in doses for migraine, is not an analgesic of choice during pregnancy and should not be used in the third trimester of pregnancy.

Good practice point tick Ibuprofen should be used with caution in pregnancy and only up to 20 weeks, if paracetamol or sumatriptan are ineffective in reducing pain.

Good practice point tick Avoid use of rimegepant in pregnancy and breastfeeding.