- Treatment choice should be tailored to the individual patient dependant on their co-morbidities and lifestyle.
- There is no one treatment better than another.
- A reduction of 30-50% in headache severity or frequency is considered a successful treatment.
- A headache diary should be provided to help quantify this improvement.
- All treatments should be trialled for at least 3 months at target dose before considering efficacy.
Migraine Prophylaxis
Formulary Choices
Propranolol. Starting dose 10-20mg twice daily. Increase by 10-20mg twice daily every 2 weeks. Target dose 80mg twice daily.
Amitriptyline. Starting dose 10mg at night (few hours before bed) Increase 10mg every 2 weeks. Target dose 30-50mg daily (max dose 100mg daily).
Nortriptyline. No formal evidence but less sedating than Amitriptyline so may be considered if Amitriptyline limited by somnolence.
Candesartan. Starting dose 4mg once daily. Increase 4mg every 2 weeks. Target dose 16mg daily.
Topiramate. Starting dose 25mg once daily. Increase 25mg every 2 weeks. Target dose 50-100mg twice daily. Following the 2024 MHRA update, Topiramate is now contraindicated in women of childbearing age unless the conditions of a pregnancy prevention plan (PPP) are fulfilled. Please find details of the PPP here, and risk awareness form here
Topiramate must never be used in pregnancy for migraine prophylaxis.
Pizotifen. Starting dose 0.5mg night. Increase 0.5mg every 2 weeks. Target dose 1.5mg night.
Amitriptyline. Starting dose 10mg at night (few hours before bed) Increase 10mg every 2 weeks. Target dose 30-50mg daily (max dose 100mg daily).
Nortriptyline. No formal evidence but less sedating than Amitriptyline so may be considered if Amitriptyline limited by somnolence.
Candesartan. Starting dose 4mg once daily. Increase 4mg every 2 weeks. Target dose 16mg daily.
Topiramate. Starting dose 25mg once daily. Increase 25mg every 2 weeks. Target dose 50-100mg twice daily. Following the 2024 MHRA update, Topiramate is now contraindicated in women of childbearing age unless the conditions of a pregnancy prevention plan (PPP) are fulfilled. Please find details of the PPP here, and risk awareness form here
Topiramate must never be used in pregnancy for migraine prophylaxis.
Pizotifen. Starting dose 0.5mg night. Increase 0.5mg every 2 weeks. Target dose 1.5mg night.
Oral CGRPs
In those with untreated migraine despite trials of at least 4 other preventative agents, please contact Neurology for advice. In those who are eligible, Neurology may advise that an oral CGRP is trialled in primary care prior to referral to the headache clinic. All patients require to keep a headache diary for 1 month as a baseline prior to commencing treatment.
Episodic migraine (>4days of migraine per month):
Chronic migraine
Monitoring: all patients commencing oral CGRPs patients are required to keep a headache diary. As above, this should be completed for 1 month prior to commencing treatment and continued whilst on treatment. If <50% improvement in headache frequency/intensity at 3 months despite medication adherence, treatment should be discontinued. If significant improvement or if a patient becomes refractory to treatment, a treatment break should be trialled.
Episodic migraine (>4days of migraine per month):
- 1st Line - Atogepant 60mg daily (Dose reduction to 10mg/day if CrCl <29mL/min or concomitant use of strong CYP3A4 inhibitors or strong OATP inhibitors)
- 2nd Line - Rimegepant 75mg alternate days
Chronic migraine
- Atogepant 60mg daily (Dose reduction to 10mg/day if CrCl <29mL/min or concomitant use of strong CYP3A4 inhibitors or strong OATP inhibitors)
Monitoring: all patients commencing oral CGRPs patients are required to keep a headache diary. As above, this should be completed for 1 month prior to commencing treatment and continued whilst on treatment. If <50% improvement in headache frequency/intensity at 3 months despite medication adherence, treatment should be discontinued. If significant improvement or if a patient becomes refractory to treatment, a treatment break should be trialled.