|Therapeutic Area||Formulary Choices||Cost for 28|
(unless otherwise stated)
|Rationale for decision / comments|
|Acute management of migraine||Related information|
CKS treatments of acute migraine
CKS prevention of migraine
|NICE recommends not using ergots or opioids for acute treatment of migraine|
|Simple analgesia||Aspirin||300mg dispersible tablets: |
|Evidence supports the efficacy of Aspirin at a dose of 900mg for acute migraine. Available OTC.|
|Ibuprofen||200mg tablets: £3.40 (84) |
400mg tablets: £3.12 (84)
600mg tablets: £5.77 (84)
|For severe headache 400mg dose recommended. 200mg and 400mg tablets available OTC.|
|Paracetamol||500mg tablets: £2.28 (100)||Soluble preparations may have a role for occasional use but have high sodium content. Available OTC. Recommended dose 1000mg.|
plus anti-emetic prescribed separately
|As above plus||Price as above||Analgesic plus anti-emetic combinations are the second line therapy option when simple analgesia alone has proved inadequate. Combination products eg. Migramax® are significantly more expensive than separate prescriptions, one component of which is available OTC.|
|Domperidone||10mg tablets: £0.93 (30) ||Affects QT .Maximum dose 10mg tds in adults and adolescents weighing 35k or more. Avoid in moderate-severe liver function and in patients with severe underlying heart problems
Drug Safety Update May 2014: Domperidone: risks of cardiac side effects
|Metoclopramide||10mg tablets: £0.74 (28)||Metoclopramide causes more acute dystonic reactions than domperidone particularly in younger patients. Maximum 5 day treatment period. MHRA warning|
|Prochlorperazine||5mg tablets: £0.94 (28)||Prochlorperazine 3mg Buccal tabs are non formulary due to very high cost|
|50mg tablets: £1.28 (6)|
100mg tablets: £1.46 (6)
|Sumatripan is included as the most cost-effective triptan. Evidence suggests little additional benefit from doses above 50mg. If patients have been initiated on injectable forms, a trial of oral sumatriptan is recommended|
|2.5mg tablets: £1.38 (6)|
2.5mg orodispersible tabs: £1.42 (6)
5mg orodispersible tabs: £11.11 (6)
|Dose for migraine is 2.5mg – 5mg strength only for patients not achieving satisfactory relief with 2.5mg dose.
There is no evidence that oro-dispersible formulations have a faster onset of action than conventional tablets.
Zolmitriptan orodispersible or rizatriptan orodispersible are significantly more cost effective alternative to rizatriptan melts (Maxalt)
|Prophylaxis of migraine||Consider prophylaxis when more than one or two attacks occur per month. See BNF for details.
The need for continuing migraine prophylaxis should be reviewed 6 months after starting.
Induction of drug overuse headache is possible for all triptans.
Risk becomes significant at 12 days per month of triptan intake, mean onest occurs after 1.7 years use.
|First-line:||Propranolol||10mg tablets: £0.89 (28)|
40mg tablets: £0.89 (28)
80mg tablets: £1.74 (56)
|Propranolol is the recommended first line prophylactic therapy for migraine.
Avoid using Propranolol MR products as significantly higher cost: Inderal-LA®(£1.91 pack of 28) and Half-Inderal LA® (£5.40 pack of 28).
|Second-line:||Topiramate||25mg tablets: £1.85 (60) |
50mg tablets: £2.09 (60)
100mg tablets: £2.74 (60)
200mg tablets: £14.00 (60)
|Topiramate is effective for migraine prophylaxis. Advise women & girls of childbearing potential that topiramate is associated with a risk of foetal malformations & can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.
Prescribe as tablet formulation not capsule because of large price difference
|Third-line:||Amitriptyline||10mg tablets: £1.20|
25mg tablets: £0.79
50mg tablets: £1.15
|NICE CG150 states that people whose migraine is well controlled with amitriptyline should continue their current treatment.|