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Home Formulary 4.0 Central Nervous System 4.7 Analgesics 4.7.4 Antimigraine drugs 4.7.4.2 Migraine prophylaxis

4.7.4.2 Migraine prophylaxis

ChoiceDrug
1st choicePropranolol tablets 10mg, 40mg, 80mg, 160mg Propranolol m/r capsules 80mg, 160mg
2nd choice

Topiramate tablets 25mg, 50mg, 100mg

(Topiramate is contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled. See MHRA.)

Prescribing Notes

  • Refer to NICE Clinical Knowledge Summaries Migraine for more comprehensive information including further preventative treatment choices
  • The aim of preventive treatment is to reduce the frequency, severity and duration of attacks and avoid medication-overuse headache (MOH)
  • Consider preventive treatment if:
    • Migraine attacks are having a significant impact on quality of life and daily function e.g. occurring frequently (more than 1 attack per week on average) or are prolonged and severe despite optimal treatment
    • The person is at risk of MOH due to frequent use of acute drugs
    • Standard analgesia and triptans are contraindicated or ineffective
  • It is essential to rule out MOH before preventive treatment is initiated. If MOH is suspected then the appropriate management is drug withdrawal rather than prevention
  • Topiramate is now contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled. See MHRA.
  • If both topiramate and propranolol are ineffective (after two months of therapy at the target dose) or are unsuitable, refer to NICE CKS Migraine or BASH Guidelines for information on other drug treatment options including amitriptyline and candesartan. If there is no benefit with an adequate trial of 3 prophylactic medicines and withdrawal of overused medication, consider referral to headache services for further management
  • Treatment is considered to have failed if there is lack of response to the highest tolerated dose after 8-12 weeks of treatment
  • Prophylaxis should be given for approx. 6 months, then consider gradual drug withdrawal
  • Pizotifen and clonidine have been widely used for many years but with little clinical trials evidence of efficacy. They should now be superseded

Cautions

  • Prescribe with caution in people at risk of metabolic acidosis.
  • Topiramate has been associated with acute myopia with secondary angle-closure glaucoma, typically occurring within 1 month of starting treatment. Seek specialist advice and stop topiramate as rapidly as feasible.
  • Careful assessment of the appropriateness of prescribing propranolol to individuals at risk of self-harm is required. See HSIB report.

 

 

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