Clinical practice guidelines for England and Wales
The National Institute for Health and Care Excellence (NICE) has published a headache guideline for those aged over 12 years. The guideline, dated 2012, updated in 2015, includes treatment for migraine.
The guideline is based on scientific evidence and is intended for primary care where most headaches can safely be diagnosed and managed. If specialist advice is necessary, the guideline recommends referral to a GP with a special interest in headache or a consultant neurologist with similar interest. The guideline highlights special considerations for women with migraine including choice of contraception, management during pregnancy and management of migraine associated with the menstrual period.
For diagnosis of headache, the guideline says that, at the first consultation, the doctor should ask for a description of the headache and any other symptoms. The doctor will want to ensure that the headache is not due to a serious underlying cause. The doctor may ask for completion of a diary over eight weeks to gather more detailed information about headaches and help them make the diagnosis.
The guideline says that, if a GP makes a diagnosis of migraine, further investigation is not usually required. A brain scan is not indicated solely to reassure the patient or the doctor. Adverse affects from scanning include exposure to radiation.
NICE guideline recommendations for migraine
The guideline recommends that for relief from a migraine attack, a healthcare professional should offer a triptan together with either a non-steroidal anti-inflammatory drug (NSAID) or paracetamol to help relieve migraine. If it is preferred to take only one drug, they may offer a triptan, an NSAID, high‑dose aspirin or paracetamol. They may also offer you an anti-sickness medicine. All of these drugs are oral drugs. If you are unable to take oral drugs, or they do not work well, you should be offered metoclopramide or prochlorperazine which are non-oral drugs. You may also be offered a non‑oral NSAID or triptan. You should not be offered an ergot or an opioid to treat migraine, and those aged under 16 should not be offered aspirin.
The guideline recommends that for treatment to help prevent future migraine your healthcare professional should offer topiramate or propranolol. You may be offered amitriptyline as a treatment option, depending on your preferences, any other health problems and the possible side effects of the drug. Topiramate can cause birth defects and this should be discussed if there is the possibility of pregnancy. Contraception should be checked and changed if necessary, because topiramate can reduce the effectiveness of some types of contraceptive drugs. If neither topiramate nor propranolol are suitable or work well, you may be offered a course of up to 10 sessions of acupuncture.
The guideline says that women with menstrual-related migraine may be offered frovatriptan or zolmitriptan to help prevent migraine. Women with migraine with aura should not usually be offered the combined pill for contraception. During pregnancy, your healthcare professional should offer paracetamol to relieve migraine. They may offer a triptan or an NSAID after discussing the risks and benefits of taking these drugs during pregnancy.