Lifestyle modifications
A lot more information about this, directed to patients, can be found on the Migraine Trust website.
Sleep in sufficient quantity is important for all headaches. Migraine can also be brought on by sleeping too much, e.g. on weekends. Lack of sleep is often a major cause of disability in cluster headaches, as the pain keeps them up all night. As always, insomnia should be primarily addressed by cognitive sleep therapy including the principles of sleep hygiene and sleep restriction, and not by medication. Amitriptyline can however be helpful as an addition.
Diet can affect headaches, primarily as skipping meals can bring on a headache. A few patients with migraine have specific triggers such as citrus or cheese but they are usually well aware of this and there’s not need to go on an extreme diet.
Drinking too much alcohol brings on a headache. In particular, red wine is often a very strong trigger for migraine. Drinking caffeinated drinks can help relieve a headache in the short term but then cause a rebound headache, similar to medication overuse headaches. The patient should therefore be advised to try stopping caffeine together.
Smoking can make all headaches worse. Many patients with cluster headache smokes, and this will usually also prevent them from having oxygen treatment.
Exercise can improve headaches. It seems that walking is not enough, and we recommend exercising enough to become short of breath at least twice a week. Relaxation exercises such as yoga / tai chi to prevent muscle tension can also be helpful.
Rescue medication
Pain killers are the main part of headache treatment. It’s important not to use pain killers too often, but it’s also important to use high enough doses or combinations of pain killers when it’s needed. If a treatment hasn’t worked a couple of times, try another combination next time or increase the dose. The goal is to become pain free within an hour.
Paracetamol is typically only helpful for mild headaches.
NSAID such as Ibuprofen or Naproxen are usually helpful for headaches. We recommend Naproxen 500mg as it has a longer lasting effect.
Aspirin is often even more effective, if tolerated. We recommend using 900 mg.
Anti-nausea medication can both help with the nausea and speed absorption of the pain killers. We usually prescribe Buccastem (prochlorperazine) 3m, but options also in clude metoclopramide and domperidone 10mg. Before using domperidone, an ECG has to be checked for QT interval. For metoclopramide and prochlorperazine, there is a small risk of neurological side effects such as tardive dyskinesia if regular or prolonged use.
Triptans are the most effective pain killers for migraine. Start with sumatriptan 50mg. If not effective, try 100mg next time. If still not effective, try adding Ibuprofen or Naproxen or Aspirin. If still not effective, add an anti-nausea medication. If still not effective try another triptan. There are four triptans on the Dorset formulary (sumatriptan, zolmitriptan, rizatriptan, frovatriptan) where frovatriptan has a much longer half life than the other three. Sumatriptan and Zolmitriptan also exists as nasal spray which should be tried if tablets fail, especially if there is significant nausea. As a last resort, sumatriptan injection can work when other forms have failed. On the BNF, there are also naratriptan, eletriptan, and almotriptan.
More about Triptans
If a patient needs more than six triptans in month, have a discussion about preventatives, but don’t be afraid to prescribe 18 if needed. They should still avoid taking them more than 2-3 days in one week but might need two in the same day.
Triptans can be safely combined with SSRI and other serotonergic medications, as long as the patient is feeling well.
Never combine with ergotamine (rarely used now).
There is extensive safety data for sumatriptan. Occasional use of other triptans is believed to be safe.
Avoid if established ischaemic heart disease or cerebrovascular disease, as triptans are mild vasoconstrictors.
Don’t start triptans after age 65 due to concern about stroke risk. If other treatments don’t work, discuss vascular risk factors with patient and make an individualised decision. If needed ask neurology for advice.
Triptans have traditionally not been recommended in hemiplegic migraines and migraine with other severe auras due to concern about stroke. In practice, the risk is low but it makes sense to wait with the triptan until the aura starts to resolve, and instead take Aspirin 900 mg at the onset of the aura. Discuss with neurology if needed.
Oral Preventative medication
All of these medications were originally develop to treat either hypertension, depression, or epilepsy and the effect on migraine were shown later. Inform the patient that the effect will build up over a couple of months and that they can reduce the number of migraines by 50% or make them milder. Unfortunately, side effects often make patients stop the medication or stay at a low dose.
It’s possible to go up to double the dose for all of these medications,, but in general patients find the higher dose difficult to tolerate for more than a few months. Pizotifen seems to help with migraine in children but not in adults. We don’t use gabapentin for migraine anymore. If migraines improve, we recommend to try to come off the preventative after a year.
| Medication | Good when | Side effects | Starting dose | Aim for dose |
|---|---|---|---|---|
| Candesartan | Hypertensive, vascular disease. | Hypotension | 2-4 mg | 16mg |
| Propranolol | Anxiety, palpitations, POTS. | Hypotension, cold hands, asthma | 10 mg bd | 80mg MR bd |
| Metoprolol | Anxiety, palpitations, POTS | Hypotension, cold hands, asthma | 25 mg | 100mg |
| Amitriptyline | Insomnia, pain, anxiety. | Drowsiness, memory difficulties, dry eyes, constipation. | 10 mg at night | 30 mg night |
| Duloxetine | Depression, anxiety, pain. | Drowsiness, nausea, weight gain. | 20 mg | 60 mg |
| Topiramate | Chronic migraine, obesity | Brain fog, anxiety, weight loss, kidney stones | 25 mg at night | 50 mg bd |
| Flunarizine (unlicensed) | Vestibular migraine | Ankle swelling, depression, parkinsonism | 5 mg at night | 10 mg at night |
Injectable preventative medication
Botox and anti-CGRP can only be prescribed in the Headache Service, and is only available for patients with chronic migraine that have failed three oral preventatives, and where medication overuse has been addressed. An occipital nerve block can give temporary relief both for migraine as well as for neck-related headaches and cluster headaches. This could be done in primary care and we’d be happy to teach you.
Botox
Injections at the hospital every 12 weeks
Anti-CGRP
Injections at home once a month:
Emgality, Ajovy and Aimovig
Nerve block
Temporary pain relief:
Cortisone and local anaesthetic
Rimegepant and Atogepant
Tablets with similar mechanism of action as the anti-CGRP injections. Rimegepant can be prescribed by GPs as an acute medication, for patients where triptans don’t help or who cannot take triptans. Atogepant can only be prescribed at the Headache Service, and then taken every day as a preventative if other options haven’t helped. At the Headache Service, we can also prescribe Rimegepant every second day as a preventative medication, but only for patients with between 4-15 headache days a month if other options don’t help. Does it sound complicated? It is, but it will probably soon be easier and these medications might over time become very common. They have almost no side effects, but can interact with a few other medications, for instance verapamil, carbamazepine, and antifungals. You can read more about atogepant in this patient information leaflet.