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Headache - migraine NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
headache in adults age 18 years and older
diagnosis and assessment of headache, including a severity assessment of the possible causes
consideration of serious causes of headache, including:
giant cell arteritis (GCA)
primary angle closure glaucoma
benign intracranial hypertension
the care map will not cover the detailed management of the conditions above, but rather the urgent assessment and timely referral to secondary care for further investigation
diagnosis and management of primary headaches, including:
 International Headache Society (IHS). Headache Classification Subcommittee of the International Headache Society (IHS). Oxford: Blackwell Publishing; 2005.
 Clinical Knowledge Summaries (CKS). Migraine. Version 1.1. Newcastle upon Tyne: CKS; 2012.
 National Institute for Health and Clinical Excellence (NICE). Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. NICE technology appraisal guidance 260. London: NICE; 2012.
 Contributors representing the Royal College of Physicians. London: 2013.
Local administrative information
Closure of Patent Foramen Ovale for Migraine
Individual Funding Request
Policy Date Adopted: 16th September 2016
The Closure of Patent Foramen Ovale for Migraine is not routinely funded by the CCG.
Note: This policy does not apply to closure of patent foramen ovale for stroke prevention.
Diagnosis of migraine is made according to criteria set by the second edition of 'The International Classification of Headache Disorders (ICHD-II)', published by The International Headache Society [5,10]
Diagnose migraine without aura (the most common form of migraine ):
diagnose when at least five attacks fulfil the following criteria:
headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
headaches have at least two of the following characteristics :
unilateral or bilateral location
moderate or severe pain intensity
aggravation by, or causing avoidance of, routine physical activity, eg walking or climbing the stairs
during the headache at least one of the following is present:
nausea and/or vomiting
photophobia or phonophobia
Diagnose migraine with aura in patients presenting with or without headache and wth one or more of the following typical aura symptoms :
visual symptoms that may be:
positive, eg flickering lights, spots or lines, and/or
negative, eg partial loss of vision
sensory symptoms that may be:
positive, eg pins and needles, and/or
negative, eg numbness
The typical aura symptoms must be:
fully reversible; and
develop gradually, either alone or in succession, over at least 5 minutes; and
last for 5-60 minutes
About one third of people with migraine report auras .
Provide the patient with :
a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded
options for management
recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers
written and oral information about headache disorders, including information about support organisations
Consider the use of headache diaries  and appropriate assessment questionnaires to support the diagnosis and management of headache .
Predisposing factors include :
depression and/or anxiety
head or neck trauma
Triggers are not as common as believed .
Potential triggers and strategies for management are :
anxiety and emotion:
try to avoid stress − relaxation techniques such as yoga may help
specific foods (generally overstated as triggers)
change in habits, eg altered sleep patterns, jet lag, changes in meal times or missing meals:
advise patient to return to normal habits as soon as possible
can precipitate a migraine in those unused to it but regular exercise may be beneficial in preventing migraine
NB: Evidence from observational studies to support the role of triggers in migraine is limited .
Complementary and alternative medicines are not recommended for the treatment or prevention of migraine (with the exception of relaxation techniques such as yoga) .
Suspect medication-overuse headache in patients with migraine, who experience chronic headache (headache more than 15 days a month) that develops or worsens following frequent use of any pain relief medication [5,7] .
Medication-overuse headache :
can occur with frequent use of any symptomatic treatment for acute headache (patients overusing triptans are more likely to have migraine-like symptoms)
may present with symptoms resembling chronic migraine
resolves following withdrawal of symptomatic treatment
Advise the patient that:
migraine can be effectively treated and tends to improve over time
at present there is no cure for migraine 
Migraine during pregnancy frequently improves but may recur following childbirth .
In general, drug treatment should be limited in pregnancy and breastfeeding. Where possible, non-pharmacological measures should be tried before considering drug therapy (such as avoidance of triggers, relaxation techniques, sufficient sleep) and encouraging the patient to use a migraine diary to identify triggers
If treatment is essential, prescribe the lowest effective dose for the shortest time. BNSSG Formulary
Offer pregnant women paracetamol first-line for the acute treatment of migraine.
Consider the use of a triptan or an NSAID (ibuprofen is preferred) after discussing the woman's need for treatment and the risks associated with the use of each medication during pregnancy.
Sumatriptan is the preferred triptan in pregnancy.
NSAIDs should be avoided in the third trimester.
Aspirin should be avoided early in pregnancy, in women attempting to conceive, and in the third trimester.
Treat breastfeeding women with the same drugs as those used in pregnancy except that::
Aspirin should be avoided completely.
Sumatriptan is the preferred triptan in breastfeeding. Sumatriptan is detected in low levels in the breast milk so infant exposure and the risks of adverse effects are low. If a mother wishes to minimize infant exposure, she should be advised to avoid breastfeeding (and discard any expressed milk) for 8 hours after treatment.
If the infant is pre-term, of low birth weight, or has other medical problems seek specialist advice.
Nausea and Vomiting:
If nausea and vomiting are problematic in pregnancy or breastfeeding consider prescribing an anti-emetic (although none are licensed in pregnancy or breastfeeding).
First line recommended treatment is an antihistamine such as promethazine or cyclizine, both of which can cause sedation.
Second line treatments are prochlorperazine and metoclopramide.
Drugs for the prevention of migraine are not recommended in pregnant or breastfeeding women. If preventive treatment is needed, seek specialist advice.
For further information on the use of drugs in pregnancy, contact the UK Teratology Information Service (UKTIS), formerly the National Teratology Information Service (NTIS), on 0844 892 0909. For further information on the use of drugs when breastfeeding, contact the UK Drugs in Lactation Advisory Service (0116 255 5779 or 0121 311 1974).
The Best Use of Medicines In Pregnancy Website (BUMPS) is run by the UK Teratology Information Service (UKTIS) and provides patient leaflets on the safety of medicine use in pregnancy.
suspect in female patients whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles 
confirm diagnosis using a headache diary for at least two menstrual cycles 
pure menstrual migraine :
patient is free from migraine at all other times
affects fewer than 10% of patients with migraine 
menstrually-related migraine :
additional attacks of migraine (with or without aura) at other time
Acute treatment of menstrual attacks of migraine is the same as for non-menstrual attacks but, because the former may have longer duration, it may be necessary to repeat treatment over several consecutive days. However, to avoid inducing medication-overuse headache, do not give treatment on :
15 or more days a month with simple analgesics; or
10 or more days a month with codeine-containing analgesics, ergot, or triptans
may exacerbate migraine, particularly if surgically induced without replacement therapy
hormone replace therapy (HRT) is not contraindicated − non-oral routes are recommended 
Combined hormonal contraceptives (CHCs):
should not be prescribed to women with migraine with aura [1,2,5,10,11]
are contraindicated in patients with migraine treated with ergotamine [1,5]
should be stopped in patients who develop new:
migraine with aura 
focal neurological signs 
Progesterone-only contraceptives are indicated in these circumstances and include oral treatment or parenteral treatment (subdermal implant or intramuscular injection)
Migraine in the hormone-free interval is best managed by continuous hormone use, without a break.
If persistent breakthrough bleeding occurs, consider continuous use for 9-12 weeks, ie 'tricycling' followed by a 3-4-day hormone-free interval.
NB: CHCs often improve migraine, however they may exacerbate it and should be changed or discontinued if they do .
Emergency parenteral treatment may be administered at home or in hospital  where oral administration will not be effective due to vomiting. Medication options include :
sumatriptan by subcutaneous injection
Diclofenac by intramuscular injection into the gluteal muscle or rectal suppositories
Prochlorperazine as buccal tablets or Intramuscular injection
metoclopramide intramuscularly or slow intravenous injection
NB: Metoclopramide and prochlorperazine can cause acute dystonias including oculogyric crisis, particularly in young and the elderly. This effect can be reversed by procyclidine intramuscular or intravenous injection, 5–10 mg (occasionally more than 10 mg), usually effective in 5–10 minutes but may need 30 minutes for relief; For the elderly use doses at the lower end of the range.
NB: Narcotics are not recommended for the emergency treatment of migraine .
NB: For patients at high future risk of needing emergency non-oral treatment, consider prescribing appropriate buccal, rectal or parenteral preperations for home use .
Advise patient to lie down in a quiet darkened room, and take oral analgesia as soon as pain (or a sensation of impending pain) develops .
Offer combination therapy, taking into account the person's preference, comorbidities, and risk of adverse events:
an oral triptan and an NSAID or
an oral triptan and paracetamol
For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan.
For patients who prefer to take only one drug, NICE recommends monotherapy with one of the following:
NSAID e.g. ibuptofen or naproxen
aspirin (900 mg)
consider an anti-emetic in addition to other acute treatment for migraine, even in the absence of nausea and vomiting.
an oral anti-emetic, eg [1,10]:
suppositories or buccal route if oral intake is prevented eg:
For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated:
offer a non-oral preparation of metoclopramide or prochlorperazine and
consider adding a non-oral NSAID or triptan if these have not been tried.
Discuss the risks medication-overuse headache with the patient .
Ask the patient to complete a headache diary and consider preventative treatment if :
migraine attacks are causing frequent disability, eg two or more attacks per month that produce disability lasting for 3 days or more
standard analgesia and triptans are either contraindicated or ineffective
migraine is of an uncommon type, such as hemiplegic migraine, or migraine with prolonged aura (consider referral or seek specialist advice)
migraine attacks are suspected of causing medication overuse (analgesics or triptans)
Rule out medication-overuse headache before preventive treatment is initiated. If this is suspected then the appropriate management is drug withdrawal rather than prevention .
Discuss the benefits and risks of prophylactic treatment for migraine, taking into account the patient's preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life .
Explain that preventive treatment reduces the frequency of attacks, but acute treatment will still be required .
Ensure patients receiving preventative treatment are followed up .
Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the person's preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life.
Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.
If topiramate and propranolol are unsuitable or ineffective, consider
a course of up to 10 sessions of acupuncture over 5–8 weeks or
For people who are already having treatment with another form of prophylaxis such as amitriptyline, and whose migraine is well controlled, continue the current treatment, if appropriate.
Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.
Advise patients that riboflavin (400mg once a day) may be effective in reducing migraine frequency and intensity . This item is a non-formulary food supplement which patients should purchase themselves. It should not be prescribed.
Consider non-pharmacological management such as:
stress management as part of a combined therapies programme [1,5]
exercise, including craniocervical exercises , and physiotherapy may help [1,5]
cognitive behavioural therapy (CBT)may be beneficial for some patients [1,5]
a course of up to 10 sessions of acupuncture over 5-8 weeks [2,4,5]
Relaxation therapy and homeopathy have no known benefit [1,5].
Advise the patient to return if adverse effects are severe enough to affect compliance during dose titration .
Review regularly during titration, eg every 2-3 weeks, to assess tolerability (first) and effectiveness .
If preventive treatment has been effective and well tolerated review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment 
If preventive treatment has been ineffective or poorly tolerated:
taper and discontinue over 2-3 weeks 
consider an alternative if there are no contraindications 
Success for prophylactic treatment of migraine is defined as one or more of the following :
a decrease in migraine attack frequency by more than 50%
a decrease in pain and disability with each individual attack
an enhanced response to acute, specific, anti-migraine therapy
Success for treatment of migraine is defined as:
complete pain relief and return to normal function within 2 hours of taking medication − in addition, patients should not have intolerable side effects  and should find their medications reliable enough to plan daily activities despite migraine headache 
Treatment has not been adequate, or was poorly tolerated :
reassess lifestyle advice
check that usage of treatment is correct
rule out medication-overuse headache
Consider referral to a neurologist if :
a complication of migraine has developed, eg migraine has become chronic
diagnosis of migraine is uncertain, eg another primary or secondary headache disorder is suspected
maximal treatment available in primary care does not adequately control the symptoms − suspect medication-overuse headache
preventative treatment does not adequately reduce the frequency of headaches