Migraine referral pathway

Acute treatment

General principals

• Migraine attacks should be treated early – when headache (not aura) starts
• Migraines respond best to 'triple therapy' – the combination of NSAIDS and prokinetic antiemetic (to make sure that the analgesics are being absorbed) and a triptan
• Mild attacks – paracetamol 1000mg ± Ibuprofen (200-800mg)
• Moderate/severe attacks – NSAID or paracetamol + triptan + prokinetic antiemetic
• Patients should be made aware of medication-overuse headache (see below)
• Opioids should be avoided where possible
• Consider rimegepant if the patient has tried at least two triptans and they did not work well enough, or triptans were contraindicated or not tolerated, and nonsteroidal antiinflammatory drugs (NSAIDs) and paracetamol were tried but did not work well enough

More information on rimegepant is available on the BSol formulary:

• Birmingham and Solihull formulary: rimegepant

Simple analgesics

Drug	Dose	Max dose 24 hours
Aspirin	300-900mg	4000mg
Diclofenac	25mg	150mg
Ibuprofen	200-600mg	2400mg
Ketoprofen	75-150mg	150mg
Naproxen	250-500mg	1000mg
Paracetamol	1000mg	4000mg
Tolfenamic acid	200mg	400mg

Triptans

Drug	Dose	Max dose 24 hours
Almotriptan	12.5mg	25mg
Eletriptan	40mg	80mg
Frovatriptan	2.5mg	5mg
Naratriptan	2.5mg	5mg
Rizatriptan	10mg	20mg
Sumatriptan	50-100mg (oral)	300mg
Sumatriptan	10-20mg (nasal spray)	40mg
Sumatriptan	3 - 6mg (subcut injection)	12mg
Zolmitriptan	2.5-5mg (oral)	10mg
Zolmitriptan	5mg (nasal spray)	10mg

Rimegepant

If the patient has tried at least two triptans and they did not work well enough, or triptans were contraindicated or not tolerated, and nonsteroidal antiinflammatory drugs (NSAIDs) and paracetamol were tried but did not work well enough consider rimegepant.

Drug	Dose	Max dose 24 hours
Rimegepant	75mg OD	75mg

Prokinetic antiemetics

If the vomiting is very early and is likely to prevent oral medication from being absorbed consider using Buccastem and Maxalt wafers – the buccal versions of prochlorperazine and rizatriptan respectively.

Drug	Dose	Max dose 24 hours
Domperidone	10mg	30mg
Prochlorperazine	10mg	30mg
Metoclopramide	10mg	30mg

Medication-overuse headache

Medication-overuse headache may occur in patients with chronic migraine who frequently use acute migraine medication (Paracetamol or Ibuprofen ≥15 days a month) or (Triptans or Opiated or mixed (≥10 days a month).

Although this should be discussed with patients, many are unable to reduce acute pain medication until established on preventative medication.

For more information on acute treatment, please visit the Headache Management System website.

• Headache Management System: migrane acute treatments

Preventative medication

Starting, stopping and switching:

• Start if on average ≥1 attack per week
• Prescribe according to other co-morbidities (i.e. if asthma – betablockers contraindicated)
• Start low and increase slow (i.e. small increments evert 1-2 weeks)
• Encourage patient to keep simple headache diary
• Unless any adverse effects, continue for 3-4 months before switching
• If <50% effective (severity or frequency of migraines) then switch
• If possible, slowly decrease and stop after 12 months. Restart if necessary

Before prescribing topiramate you need to ensure that patients of childbearing potential have signed a risk acknowledgment form. Details of the Pregnancy Prevention Programme can be found on the GOV.UK website.

• Topiramate annual risk awareness form
• Topiramate: introduction of new safety measures, including a Pregnancy Prevention Programme

If you are struggling to control a patient's headaches despite following the guidance, please get in touch via the advice and referral service. It is important that you include details of:

• which medications have been tried
• the maximum dose reached, and
• the reason for discontinuation

Also, please follow the principles of how to make a good Neurology referral:

• How to make a good Neurology referral

Drug	Start dose	Target daily dose
Amitriptyline	10mg	25-150mg
Candesartan	2mg	8-16mg
Propranolol	20mg	240mg
Atogepant	60mg	60mg OD
Rimegepant	75mg OD on alternate days	75mg OD on alternate days
Topiramate	25mg	25-250mg

Atogepant and Rimegepant have been approved for primary care use:

• Atogepant is a preventative treatment and should be tried in patients who have tried and failed three other preventative medications. It can be used in patients who have four or more migraine days per month including those who have 15 or more migraine days per month
• Rimegepant can be used as a preventative migraine medication, if the patient has tried and failed three other preventative medications. It can be used in patients who have between four and 15 migraine days per month

More information on Atogepant and Rimegepant are available on the BSol formulary:

• Birmingham and Solihull formulary: incorporating the BSSE APC formulary

For more information on migraine preventatives, please visit the Headache Management System website.

• Headache Management System: migraine preventive treatments

Specific situations

• Menstrual migraine
• Migraine in pregnancy

When to refer

Referral to secondary care should be done via the advice and referral system. Please follow the guidelines on how to make a good Neurology referral:

• How to make a good Neurology referral

• Chronic migraine (≥15 days headache a month)
• Failed on 3+ oral preventatives and Atogepant
• If you think that it is not migraine but a more complex headache (e.g. cluster headache/TAC or trigeminal neuralgia)
• Before referring the patient, consider whether they may be elligible for rimegepant as a preventative therapy

In addition to following the how to make a good Neurology referral guidance, please state:

• Headache frequency
• Which preventatives have been trialled
• Dose trialled
• Reason for discontinuation
• Suspected diagnosis