Management

• once a diagnosis of migraine has been established, structured patient education and expectation management are essential components of primary care care planning (1)
  
  
• core educational messages for patients include:
  • migraine is a biological, often inherited neurological susceptibility to recurrent headaches that can be effectively managed and controlled, though not cured
  • reassuring the patient that, with specific exceptions (such as females with aura or those who smoke and use combined hormonal contraception), migraine is not associated with serious structural cerebrovascular or intracranial disease
  • advising that establishing an effective individualized treatment plan takes time and iterative review
    
• clinical management is broadly categorized into general non-pharmacological measures, acute attack management, and prophylactic treatment

General Management Measures

Trigger Identification and Modification

• maintain a headache diary for at least 3 months to identify personal triggers (e.g., stress, irregular sleep patterns, skipped meals, dehydration, specific dietary factors) and guide lifestyle adjustments

Lifestyle Optimization

• encourage regular sleep hygiene, adequate hydration, routine meals, regular aerobic exercise, and stress reduction strategies

Patient Empowerment

• provide clear written information and agree an individualized action plan covering both acute relief and when to seek preventive options

Management Pathways

Acute Attack Management

• step-ladder vs stratified approach: offer combination therapy (oral triptan plus NSAID or paracetamol) or monotherapy early in the attack when gastric stasis is minimal
• anti-emetics: consider co-prescribing prokinetic anti-emetics (e.g., metoclopramide or domperidone) to manage nausea and improve oral drug absorption
• second-line and specialized options: non-oral routes, or oral calcitonin gene-related peptide (CGRP) receptor antagonists (rimegepant), for patients in whom first-line therapies are ineffective, contraindicated, or not tolerated
• avoidance of medication overuse: strictly avoid opioids and codeine-containing analgesics due to lack of efficacy and high risk of medication overuse headache

Migraine Prevention (Prophylaxis)

• indication: offer prophylaxis for frequent attacks (typically >=4 migraine days per month) or severe functional impairment
• first-line oral pharmacotherapy: consider propranolol, topiramate (subject to strict Pregnancy Prevention Programme requirements), or amitriptyline
• alternative and specialist options: acupuncture or riboflavin (400 mg daily) for oral intolerance; specialist therapies include botulinum toxin type A and CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) for refractory or chronic migraine

Reference:

1. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management. NICE Clinical Guideline [CG150]. Updated June 2025.