Prescribing Notes
- The choice of preventive treatment depends primarily upon the side-effect profile of the drug and co-existing morbidities, refer to NICE CG150, CKS and Cautions section.
- 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
- 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. See NICE CG150 and BASH.
- If the first treatment tried does not work or is not tolerated, try a second option and then the remaining option, unless unsuitable because of safety concerns.
- 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 They should now be superseded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
- Careful assessment of the appropriateness of prescribing propranolol to individuals at risk of self-harm is required. See HSIB report.
- Topiramate is now contraindicated in pregnancy and in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled. See MHRA.
- Consult individual product SPC for full details on cautions.