4.7.

4 Antimigraine Drugs

Antimigraine Drugs
Relief of Acute Migraine Attack

Step 1 NSAID ± paracetamol ± prokinetic agent

Paracetamol
Soluble tablets, dose 1g stat .....................................................

NSAID

Aspirin
Soluble tablets, dose 900mg stat ................................................
Ibuprofen tablets 400mg stat ....................................................
Naproxen tablets 500mg stat ....................................................

Diclofenac soluble tablets 50mg stat..........................................

Diclofenac suppositories 50mg stat............................................

Prokinetic agent

Metoclopramide
10mg stat dose (care, increased risk of extrapyrimidial side effects in young adults
particularly females).
Metoclopramide Solution 5mg in 5ml................
Domperidone tablets 10mg tablets, 20mg stat dose..............
Domperidone Suppositories 30mg, 60mg stat dose...................

Step 2 Triptans

Sumatriptan
50mg tablets, subcutaneous injection, nasal spray.........................................
Frovatriptan*
Tablets

Notes
• Ensure diagnosis of migraine is correct. Triptans are expensive and ineffective in all other
types of headache.
• As many patients respond to simple analgesics, it is sensible to try these first.
• Sumatriptan is also available in a wide variety of dose forms which may suit particular
needs and tablets are available generically.
• Sumatriptan 50mg and 100mg are equally efficacious and 50mg causes less side effects.
• Whichever treatment is chosen, the patient should be encouraged to take the medication as
soon as they feel an attack coming on.
• Triptans are contra-indicated in ischaemic heart disease, previous MI/CVE/TIA, coronary
vasospasm, uncontrolled hypertension and peripheral vascular disease.
• Nasal or subcutaneous preparations should be considered in severe migraine or where
vomiting precludes oral treatment or where oral triptans have been ineffective.
• Orodispersible and ‘Melt’ formulations of triptans offer no clinical advantage.
• Be alert for medication overuse headache.

*Frovatriptan
• Frovatriptan has been added to the formulary, as the first line, second line option agreed by
Primary Care D&T 2nd Feb 2012
• Frovatriptan is suitable for use in patients with a diagnosis of migraine in whom the first
line agent of choice (sumatriptan) has not been effective or tolerated.
• Frovatriptan has an efficacy and side effect profile similar to zolmitriptan but at a reduced
cost to the NHS (estimated annual savings of approx £20k).
• Frovatriptan has a significantly longer half life than zolmitriptan, indicating that it may offer
an advantage for patients who experience headaches of longer duration, including female
patients with menstrually associated migraine*.
• Patients with recurring migraine requiring the repeated use of triptans (i.e. more than 36
tablets per year) may benefit from the longer duration of action of frovatriptan*.
• * Clinical evidence to support these specific benefits is currently limited.