New guideline for pharmacological management of migraine

The Scottish Intercollegiate Guidelines Network (SIGN) has issued new guidelines for pharmacological management of adults with acute migraine, and prophylaxis for patients with an episodic or a chronic migraine or medication overuse headache.

Migraine is a headache of varying intensity, accompanied by sensitivity to light and sound and nausea. It is characterized by recurrent headaches that vary from moderate to severe. It is the most common underlying headache disorder in patients with medication overuse headache.

This guideline was developed using a standard methodology based on a systematic review of the evidence.

Recommendations for Treatment of Acute Migraine:

• Aspirin (900 mg) is recommended as first-line treatment.


• Ibuprofen (400 mg) is recommended as first-line treatment. If ineffective, the dose should be increased to 600 mg.


• Triptans are recommended as first-line treatment. The first choice is sumatriptan (50–100 mg), but others should be offered if sumatriptan fails.


• Combination therapy using sumatriptan (50–85 mg) and naproxen (500 mg) should be considered for the treatment of patients with acute migraine.

Recommendations for Treatment of Chronic or Episodic Migraine:

• Propranolol (80–160 mg daily) is recommended as a first-line prophylactic treatment for patients with episodic or chronic migraine.


• Topiramate (50–100 mg daily) is recommended as a prophylactic treatment for patients with episodic or chronic migraine.


• Amitriptyline (25–150 mg at night) should be considered as a prophylactic treatment for patients with episodic or chronic migraine.


• Candesartan (16 mg daily) can be considered as a prophylactic treatment for patients with episodic or chronic migraine.


• Sodium valproate (400–1,500 mg daily) can be considered as a prophylactic treatment for patients with episodic or chronic migraine.


• Prescribers should be aware that sodium valproate is associated with an increased risk of fetal malformations and poorer cognitive outcomes in children exposed to valproate in utero. For women who may become pregnant sodium valproate should only be considered as a prophylactic treatment when other treatment options have been exhausted and patients are using adequate contraception.


• Botulinum toxin A is recommended for the prophylactic treatment of patients with chronic migraine where medication overuse has been addressed and patients have been appropriately treated with three or more oral migraine prophylactic treatments.

Recommendations for Medication-Overuse Headache:

• When starting acute treatment, healthcare professionals should warn patients about the risk of developing medication-overuse headache.


• In patients overusing acute treatment, medication overuse should be addressed.

Image Courtesy: Scottish Intercollegiate Guidelines Network

For further information click on the link: http://sign.ac.uk/assets/sign155.pdf