Migraine Treatment Prescribed by UK Doctors

Migraine is a complex neurovascular disorder characterised by recurrent episodes of moderate-to-severe headache, typically unilateral and pulsating, lasting 4-72 hours.

The International Classification of Headache Disorders (ICHD-3) distinguishes migraine without aura (75% of cases) from migraine with aura (25%), the latter featuring transient visual, sensory, or language disturbance preceding the headache by 5-60 minutes.

Pathophysiology centres on cortical spreading depression — a wave of neuronal depolarisation that propagates across the cortex at 3-5 mm per minute, activating trigeminal afferents and triggering meningeal vasodilation, neurogenic inflammation, and pain signalling.

Calcitonin gene-related peptide (CGRP) is the key neuropeptide mediating this cascade.

The UK prevalence is approximately 15%, translating to over 10 million affected adults. Women are affected 3:1 compared with men, driven largely by oestrogen fluctuation.

Migraine peaks between ages 25-55, coinciding with the most productive working years, and costs the UK economy an estimated £3.42 billion annually in lost productivity.

Triggers vary between individuals but commonly include:

• Hormonal fluctuation (menstruation, combined oral contraceptive use)
• Sleep disruption (both excess and deficit)
• Stress and post-stress let-down periods
• Dietary factors (alcohol, caffeine withdrawal, dehydration)
• Sensory overload (bright light, strong odours, loud noise)

Accurate diagnosis requires excluding secondary headache causes.

Red flags that mandate urgent investigation include thunderclap onset (reaching peak intensity within 5 minutes), new headache after age 50, headache with fever and neck stiffness, progressive headache with focal neurological signs, and headache triggered by Valsalva manoeuvre or postural change.

Effective acute treatment aims to render the patient pain-free within two hours with no recurrence within 24 hours.

NICE CG150 recommends a stratified approach based on attack severity rather than step-care within an individual attack.

Triptans (5-HT1B/1D receptor agonists) are the gold-standard acute treatment.

They constrict dilated meningeal vessels, inhibit trigeminal neuropeptide release, and block pain transmission in the brainstem.

Sumatriptan 50-100 mg oral is most commonly prescribed. Onset occurs within 30 minutes, with 59% of patients pain-free at 2 hours with the 100 mg dose.

Subcutaneous sumatriptan 6 mg provides faster onset (10-15 minutes) for severe attacks. A nasal spray (20 mg) suits patients with prominent nausea.

Zolmitriptan 2.5-5 mg has similar efficacy and is available as an orodispersible tablet. Rizatriptan 10 mg has the fastest oral onset (approximately 30 minutes to meaningful relief).

Frovatriptan 2.5 mg has a longer half-life (26 hours) with lower recurrence rates, making it optimal for prolonged or menstrual migraine.

Non-triptan acute options include:

• Aspirin 900 mg or ibuprofen 400 mg taken early with an antiemetic (domperidone 10 mg or metoclopramide 10 mg)
• Paracetamol 1 g: inferior to NSAIDs for moderate-severe attacks but suitable for milder episodes
• Combination analgesics containing caffeine provide modest additional benefit

Medication-overuse headache (MOH) is a critical concern.

Using triptans on 10+ days per month, or simple analgesics on 15+ days, for 3 consecutive months transforms episodic migraine into chronic daily headache.

Management requires structured withdrawal under clinical supervision, often with a bridging short course of naproxen.

Preventive therapy is indicated when migraine occurs on 4 or more days per month, attacks are prolonged or poorly responsive to acute treatment, or acute medication use approaches overuse thresholds.

NICE CG150 provides clear guidance on first-line prophylactic agents.

Propranolol (80-160 mg daily) is the most established prophylactic, reducing migraine frequency by 40-50% in responders.

It is particularly suitable for patients with concurrent anxiety or essential tremor. Contraindications include asthma, heart block, and severe peripheral vascular disease.

A trial of 8-12 weeks at therapeutic dose is needed before judging efficacy.

Topiramate (50-100 mg daily, titrated slowly from 25 mg) matches propranolol in efficacy and additionally causes weight loss of 2-4 kg, which may benefit overweight patients.

Cognitive side effects — word-finding difficulty, reduced concentration — affect 10-15% and are the most common reason for discontinuation. Topiramate is teratogenic and contraindicated in pregnancy.

Amitriptyline (10-75 mg at night) is widely used off-label. It is particularly valuable when migraine coexists with tension-type headache, insomnia, or chronic pain.

Anticholinergic side effects (dry mouth, drowsiness, weight gain) limit titration in some patients.

Candesartan (8-16 mg daily) is an emerging option with RCT evidence of efficacy comparable to propranolol and a favourable side-effect profile. It suits patients with coexistent hypertension.

NICE recommends:

• A minimum 8-week trial at adequate dose before switching
• Gradual withdrawal after 6-12 months of good control to reassess ongoing need
• Headache diary maintenance to track frequency, severity, and medication use
• Avoiding concurrent use of triptans and propranolol in patients with aura (theoretical vasoconstriction risk)

For patients with chronic migraine (15+ headache days per month, at least 8 with migraine features) refractory to 3 oral prophylactics, NICE TA260 approves botulinum toxin type A injections every 12 weeks.

Behavioural modification and trigger management complement pharmacological prophylaxis and, for patients with infrequent attacks, may be sufficient as standalone strategies.

Evidence from multiple RCTs supports the following interventions.

Sleep regularity is among the most impactful modifiable factors. Both sleep deprivation and oversleeping trigger attacks.

Maintaining consistent wake and sleep times — including weekends — reduces migraine frequency by approximately 30% in observational studies.

Sleep disorders (insomnia, sleep apnoea) are highly comorbid with migraine and warrant separate treatment.

Aerobic exercise at moderate intensity for 30-45 minutes three times per week reduces migraine frequency comparably to topiramate in a Swedish RCT.

The mechanism involves endorphin release, improved cardiovascular fitness, and stress reduction. Patients should build up gradually, as sudden intense exertion can trigger attacks.

Stress management through mindfulness-based stress reduction (MBSR) or progressive muscle relaxation has demonstrated efficacy in multiple trials.

A Cochrane review found relaxation training reduces headache frequency by 35-40% with sustained benefit over 12 months.

Dietary and supplement recommendations:

• Magnesium 400-600 mg daily (magnesium citrate or glycinate): reduces migraine frequency by 41% in RCTs
• Riboflavin (vitamin B2) 400 mg daily: 50% responder rate in a placebo-controlled trial after 3 months
• Coenzyme Q10 100 mg three times daily: number needed to treat of 3 for 50% frequency reduction
• Adequate hydration: 2-2.5 litres daily; dehydration is an underrecognised trigger

Trigger avoidance requires a structured headache diary. Common dietary triggers include alcohol (especially red wine), aged cheese, and processed meats containing nitrates.

However, overenthusiastic trigger avoidance can become counterproductive and anxiety-provoking.

Evidence suggests that regular, moderate exposure to mild triggers may reduce sensitivity over time — a principle known as desensitisation.

Hormonal management for menstrual migraine includes perimenstrual frovatriptan 2.

5 mg twice daily (NICE-endorsed) or continuous combined hormonal contraception to suppress cyclical oestrogen withdrawal.

Most migraines are managed effectively with a combination of acute treatment and prophylaxis.

Certain presentations, however, demand prompt clinical evaluation to exclude serious secondary causes or manage complications.

Thunderclap headache — reaching maximum intensity within 5 minutes — requires emergency assessment to exclude subarachnoid haemorrhage, cerebral venous sinus thrombosis, or reversible cerebral vasoconstriction syndrome.

Call 999 or attend A&E immediately.

Migraine with prolonged aura lasting more than 60 minutes raises concern for migrainous infarction, a rare but serious complication.

Neuroimaging (MRI with diffusion-weighted sequences) is indicated. Triptans and ergotamines are relatively contraindicated during prolonged aura.

Status migrainosus — a debilitating migraine lasting over 72 hours despite treatment — may require parenteral therapy in an emergency department, typically IV metoclopramide, IV magnesium sulphate, or a short course of oral prednisolone.

Other red flags warranting urgent GP or specialist referral:

• New-onset migraine after age 50 (consider giant cell arteritis, space-occupying lesion)
• Progressive increase in headache frequency or severity over weeks
• Headache with papilloedema (raised intracranial pressure)
• Aura symptoms that are always on the same side (structural lesion must be excluded)
• Headache with fever, neck stiffness, and photophobia (meningitis until proven otherwise)
• Migraine unresponsive to 2 or more prophylactic agents at adequate doses for adequate duration

NICE recommends referral to a specialist headache service for patients with chronic migraine (15+ headache days per month for 3+ months) who have not responded to at least 3 preventive treatments.

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are available through NHS specialist clinics under NICE TA764 for eligible patients.