29/02/24 - atogepant tablets 10mg, 60mg SMC2599 added.
29/02/24 - rimegepant oral lyophilisate 75mg SMC2521 and 2603 added.
Base selection of migraine prophylaxis on age, gender and co-morbidity:
Titrate over several weeks and continue for a further 3 months, then assess and discontinue if ineffective.
Other antiepileptic drugs for migraine prophylaxis, the use of which should be discussed with a specialist, include gabapentin off-label: refer to BNF for dosing instructions.
Flunarizine unlicensed is used under specialist advice in patients with episodic migraine with failure to, or side-effects from, classical preventative migraine therapy.
Guidelines:
Tablets 10mg, 40mg
40mg 2 to 3 times daily; maintenance 80 to 160mg daily.
Modified release capsules 80mg, 160mg
maintenance 80 to 160mg daily.
Tablets 10mg, 25mg, 50mg
Migraine prophylaxis: initially 10mg at night, increased if necessary to maintenance of 50 to 75mg at night.
If amitriptyline is poorly tolerated consider nortriptyline.
Tablets 10mg, 25mg
Migraine prophylaxis if amitriptyline is poorly tolerated off-label: initially 10mg at night, increased if necessary to maintenance of 50 to 75mg at night.
The MHRA advises that all females of childbearing potential being treated with topiramate must follow the requirements of the Pregnancy Prevention Programme:
Pregnancy should be excluded before treatment initiation.
Highly effective contraception must be used during and for at least 4 weeks after stopping treatment.
SPS article: Using contraception with enzyme-inducing medicines (Feb 2023).
Tablets 25mg, 50mg, 100mg
Migraine prophylaxis: initially 25mg at night for 1 week, increased in increments of 25mg/day at weekly intervals up to 50mg twice daily. Some patients may experience a benefit at 25mg twice daily. See SPC for dosing in renal impairment.
Valproate medicines are contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met (MHRA advice April 2018)
Crushable tablets 100mg
Migraine prophylaxis: off-label, initially 200mg twice daily; doses up to 500mg twice daily are effective in most patients.
Enteric coated tablets 200mg, 500mg
Migraine prophylaxis: off-label, initially 200mg twice daily; doses up to 500mg twice daily are effective in most patients.
Limited value in prophylaxis of migraine (SIGN 155). It may cause increased appetite and weight gain. It can also cause drowsiness and so night-time dosing may help prevent day-time sedation. Use with caution in patients with a history of epilepsy.
Tablets 500 micrograms, 1·5mg
Initially 500 micrograms at night increased gradually to usual dose of 1·5mg at night or in 3 divided doses; may be further increased up to maximum daily dose of 4·5mg (but rarely necessary), maximum single dose 3mg.
Solution for injection in a pre-filled pen 70mg/mL (specialist initiation and supply only)
Prophylaxis of migraine in adults with chronic migraine, who have at least four migraine days per month and in whom at least three prior prophylactic treatments have failed.
As per SMC 2134: for the prophylaxis of migraine in adults who have at least four migraine days per month.
SMC restriction: patients with chronic migraine and in whom at least three prior prophylactic treatments have failed.
Solution for injection pre-filled syringes 225mg/1·5ml (hospital use only)
225mg once a month OR 675mg every three months.
See SMC advice 2226.
For prophylaxis of migraine in adults who have at least four migraine days per month.
SMC restriction: for the treatment of patients with chronic and episodic migraine who have had prior failure on three or more migraine preventive treatments.
Homecare is the preferred option - contact nhsh.homecare@nhs.scot.
Solution for injection pre-filled pens 120mg/ml (hospital use only)
240mg loading dose THEN 120mg injected subcutaneously once a month
See SMC advice 2313.
Prophylaxis of migraine in adults who have at least 4 migraine days per month.
SMC restriction: for the treatment of patients with chronic and episodic migraine who have had prior failure on three or more migraine preventive treatments.
Concentrate for solution for infusion 100mg (Restricted: hospital use only)
See SMC advice 2547: prophylaxis of migraine in adults who have at least 4 migraine days per month.
SMC restriction: for patients with chronic and episodic migraine who have had prior failure on three or more migraine preventive treatments.
Tablets 10mg, 60mg (Aquipta®)
Prescribing restrictions:
SMC2599: Prophylaxis of migraine in adults who have at least four migraine days per month.
Ordering atogepant:
AbbVie Direct ordering contact details:
Customer Services
Tel: 0800 783 1699
Email: orders.kr@abbvie.com
Oral lyophilisate 75mg (Vydura®)
Prescribing restrictions:
SMC2603: For the preventive treatment of episodic migraine in adults who have at least four migraine attacks per month.
SMC restriction: for patients with episodic migraine who have at least 4 migraine attacks per month, but fewer than 15 headache days per month and who have had prior failure on three or more migraine preventive treatments.
MHRA advice: Botulinum toxin products: rare but serious risks (December 2014)
Powder for solution for injection vial 50 units, 100 units, 200 units (Botox®) (specialist use only)
As per SMC692/11: prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine).
SMC restriction: use in adults with chronic migraine whose condition has failed to respond to ≥3 prior oral prophylactic treatments, where medication overuse has been appropriately managed.
Preparations are not interchangeable.
TAM (Treatments and Medicines) NHS Highland