For patients with migraine maintaining a regular routine is important, including the following:
Candesartan: target dose 16 mg daily.
Use of candesartan should be avoided during pregnancy and breastfeeding. Women using candesartan who are planning to become pregnant, or who are pregnant, should seek advice from their healthcare professional on switching to another therapy.
Propranolol: target does 80 mg twice a day.
Amitriptyline: target dose 30–50 mg at night. In patients who cannot tolerate amitriptyline a less sedating tricyclic antidepressant should be considered.
Amitriptyline: target dose 30–50 mg at night. In patients who cannot tolerate amitriptyline a less sedating tricyclic antidepressant should be considered.
Oral calcitonin gene-related peptide (CGRP) receptor antagonists:
Atogepant is recommended for patients with episodic or chronic migraine who have at least four migraine days per month, where medication overuse headache has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.
Rimegepant is recommended for the prophylactic treatment of patients with episodic migraine (4 to 14 days per month), where medication overuse headache has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.
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.
Botulinum toxin A:
Botulinum toxin A: for patients with chronic migraine where medication overuse has been addressed and patients have been appropriately treated with three or more oral migraine prophylactic treatments. It is not recommended for patients with episodic migraine.
Botulinum toxin A should only be administered by appropriately trained individuals under the supervision of a headache clinic or the local neurology service.
CGRP monoclonal antibodies:
Erenumab, fremanezumab, galcanezumab and eptinezumab are recommended for the prophylactic treatment of patients with chronic migraine where medication overuse has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.
Fremanezumab, galcenezumab and eptinezumab can be considered for the prophylactic treatment of patients with episodic migraine where medication overuse has been addressed and patients have not benefitted from appropriate trials of three or more oral migraine prophylactic treatments.
Topiramate: target dose 50 mg twice a day (use if propranolol fails)
Prescribers should be aware that topiramate is associated with an increased risk of serious
developmental disorders, congenital malformations and low birth weight in children exposed to
topiramate in utero. For women who may become pregnant, topiramate should only be considered
as a prophylactic treatment when:
• other treatment options have been exhausted
• patients are using highly-effective contraception in line with the MHRA Topiramate Pregnancy
Prevention Programme.
Before commencing treatment, women should be informed of:
• the risks associated with taking topiramate during pregnancy
• the risk that potentially harmful exposure to topiramate may occur before a woman is aware
she is pregnant
• the need to use effective contraception
• the need to seek urgent advice on migraine prophylaxis and stopping topiramate if planning
a pregnancy
• the need to stop taking topiramate (for migraine prevention) straight away if they do become
pregnant and contact their GP.
A washout period of at least 4 weeks after the last dose of topiramate is advised before trying for a
pregnancy.
Topiramate should not be used during breastfeeding.
Flunarazine: target dose 10 mg daily.
Flunarazine should be avoided during pregnancy and breastfeeding. Women using flunarazine who are planning to become pregnant, or who are pregnant, should seek advice from their healthcare professional on switching to another therapy.
Sodium valproate: target dose 600 mg twice a day (in patients over age 55).
Although initiation of valproate is not recommended for those under the age of 55, for those who are on it and who fulfil MHRA requirements, inform the patient of the risks to children exposed to valproate in utero and the need to use effective contraception - see www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements.
Check the Medicines and Healthcare products Regulatory Agency (MHRA) website for current advice before prescribing topiramate or sodium valproate.
Pizotifen: target dose 3–4.5 mg (lacking evidence but this is a well-established, widely-used therapy.
Therapies to avoid during pregnancy or breastfeeding:
Check the Medicines and Healthcare products Regulatory Agency (MHRA) website for current advice.
Topiramate
Prescribers should be aware that topiramate is associated with an increased risk of serious
developmental disorders, congenital malformations and low birth weight in children exposed to
topiramate in utero. For women who may become pregnant, topiramate should only be considered
as a prophylactic treatment when:
• other treatment options have been exhausted
• patients are using highly-effective contraception in line with the MHRA Topiramate Pregnancy
Prevention Programme.
Before commencing treatment, women should be informed of:
• the risks associated with taking topiramate during pregnancy
• the risk that potentially harmful exposure to topiramate may occur before a woman is aware
she is pregnant
• the need to use effective contraception
• the need to seek urgent advice on migraine prophylaxis and stopping topiramate if planning
a pregnancy
• the need to stop taking topiramate (for migraine prevention) straight away if they do become
pregnant and contact their GP.
A washout period of at least 4 weeks after the last dose of topiramate is advised before trying for a
pregnancy.
Topiramate should not be used during breastfeeding.
Sodium valproate
Although initiation of valproate is not recommended for those under the age of 55, for those who are on it and who fulfil MHRA requirements, inform the patient of the risks to children exposed to valproate in utero and the need to use effective contraception - see CoSRH Guidelines & Statements | CoSRH.
Pharmacological management of migraine (SIGN)