Management of acute treatment of migraine

NICE suggest acute treatment (1)

• offer combination therapy with an oral tripta nand an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events
• for young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
• 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:
  • consider a non-oral preparation of metoclopramide or prochlorperazine and
  • consider adding a non-oral NSAID or triptan if these have not been tried

These are best taken early in the attack when absorption may be least inhibited by gastric stasis. These drugs should be used without codeine or dihydrocodeine (2)

• codeine and dihydrocodeine are used extensively in OTC combination analgesics;
  • they provide small additional benefit in a range of painful conditions but evidence of this does not extend to headache and it is at the expense of increased side-effects
  • also these drugs are frequently implicated in medication overuse headache

An anti-emetic such as metoclopramide or domperidone not only relieves nausea that accompanies may migraine attacks but also enhances the efficacy of simultaneously administered oral analgesics (3).

Note that because triptans are agonists for receptors of multiple 5-HT subtypes, they can cause vasoconstriction and are contraindicated in patients with known or suspected vasospastic or ischemic vascular disorders and in patients with uncontrolled hypertension (4)

• adverse effects include limb heaviness; flushing; paresthesia; and tightness in the chest, neck, or throat
  • these effects are almost always benign and can be mitigated by reducing the dose, switching to an alternative triptan, or treating earlier in the attack

Consult the respective Summary of Product Characteristics before prescribing of the medication mentioned.

Notes (2):

• Migramax ®(lysine acetylsalicylate 1620 mg [equivalent to aspirin 900mg] plus metoclopramide 10mg per sachet) and Paramax ®sachets (paracetamol 500mg plus metoclopramide 5mg per sachet) are convenient preparations; there is no other way at present to give metoclopramide in a soluble oral formulation
• there is little evidence for the efficacy of paracetamol alone
• may be specific contraindications to aspirin or to other NSAIDs. In children under 16 years of age aspirin should be avoided. Metoclopramide and prochlorperazine are not recommended for children or adolescents
• if a patient is vomiting and consequently oral analgesics are not being adequately absorbed then consider:
  • diclofenac suppositories 100mg for pain plus domperidone suppositories 30mg

Reference:

1. NICE (December 2021). Headaches - Diagnosis and management of headaches in young people and adults
2. British Association for Study of Headache guidelines, 2004.
3. Drug and Therapeutics Bulletin 1998; 36(6):41-4.
4. Niushen Zhang, Matthew S. Robbins. Migraine. Ann Intern Med. [Epub 10 January 2023]. doi:10.7326/AITC202301170