19th June 2023

Management

• Avoidance of triggers where identifiable. Common triggers include disturbed sleep, irregular meals, caffeine excess, and stress.

• Avoidance of medication overuse headaches by restricting acute analgesic medication to a maximum of 2 days a week.

• Use of combined hormonal contraception is contraindicated in women who experience migraine with aura due to the risk of vascular events; alternative contraceptive options should be explored with the patient if required.

• Options for acute pharmacological management include:
  • Simple analgesia, e.g. ibuprofen, high dose aspirin (900mg) or paracetamol.
  • Triptan, e.g. sumatriptan (first choice), available in intranasal or subcutaneous formulations if unable to tolerate orally.
  • Consider antiemetics, e.g. metoclopramide or prochlorperazine, even in the absence of nausea and vomiting.
  • Avoid opioids

• Preventative treatment can be considered if migraines are frequent or severe enough to significantly impact the person’s quality of life, or if acute treatments are ineffective. Options for pharmacological prevention of migraine include:
  • Propranolol
  • Topiramate (contraindicated in pregnancy)
  • Amitriptyline
  • Frovatriptan (unlicensed), Zolmitriptan (unlicensed) for Menstrual related Migraine

NICE recommends referral to neurology if trial of 3 or more drugs is unsuccessful or if there is a development of atypical or red flag features.

Management of migraine in pregnancy and breastfeeding

• 1st line acute treatment – paracetamol
• 2nd line treatment – Ibuprofen (1st and 2nd trimester only) or triptan if paracetamol is ineffective.

NSAIDs are contraindicated in the 3rd trimester of pregnancy due to the risk of premature closure of ductus arteriosus.

Recommendation is to avoid triptan unless the potential benefit outweighs the risk and to minimise exposure of the drug to the infant by avoiding breastfeeding for 12 hours post treatment.