Executive summary (high-yield framing)
Migraine management is won by early acute treatment, avoiding medication overuse headache, and choosing a prevention plan for people with frequent/disabling attacks. Most patients can be managed in primary care with clear escalation criteria.
- Acute: NSAID or paracetamol + consider a triptan; add an antiemetic if nausea/vomiting.
- Prevent: consider when attacks are frequent (e.g., ≥4 migraine days/month) or disabling despite acute treatment.
- Escalate: chronic migraine or failure of multiple preventatives may unlock NICE-funded options (Botox/CGRP mAbs/gepants) via specialist services.
Acute treatment (practical choices)
- First line: NSAID (e.g., ibuprofen/naproxen) or paracetamol; take early in the attack.
- Triptan: consider (e.g., sumatriptan, rizatriptan) especially if NSAID alone inadequate; avoid in uncontrolled hypertension/ischaemic heart disease (check contraindications).
- Antiemetic: consider metoclopramide or prochlorperazine (follow local guidance).
- Rescue: if severe/prolonged or with dehydration, consider urgent care assessment.
Medication overuse: regular use of acute medicines can drive chronic headache. As a rule of thumb, aim to keep triptans/opioids on <10 days/month and simple analgesics on <15 days/month (use local guidance).
Prevention (stepwise, GP-friendly)
- Start with: lifestyle triggers, sleep regularity, caffeine moderation, and a headache diary.
- First-line preventatives (examples): propranolol, topiramate, or amitriptyline (choice depends on comorbidity and contraindications).
- Menstrual migraine: consider short-term perimenstrual strategies and specialist advice where needed.
Review after 8–12 weeks at an adequate dose. Continue if effective; taper after sustained control where appropriate.
Specialist escalation and NICE Technology Appraisals (snapshot)
- Chronic migraine (typically ≥15 headache days/month, with ≥8 migraine days): may be eligible for botulinum toxin type A (NICE TA260) after failure of ≥3 preventatives.
- CGRP monoclonals for prevention after failure of ≥3 preventatives (specialist initiation): examples include galcanezumab (TA659), erenumab (TA682), fremanezumab (TA764), and eptinezumab (TA871).
- Gepants: rimegepant is recommended for acute migraine (TA919) and prevention in eligible adults (TA906); atogepant is recommended for prevention in eligible adults (TA973).
In practice: these are usually accessed via neurology/headache services with commissioning criteria. Document failed preventatives, migraine-day counts, and impact scores to support referral.