Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

• triptans, opioids, ergots, or combination analgesic medications on 10 days per month or more or

• paracetamol, aspirin, or an non-steroidal anti-inflammatory drug (NSAID), either alone or in any combination, on 15 days per month or more

Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person’s preference, comorbidities, and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan

In November 2015, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. See NICE's information on prescribing medicines.
 

For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg), or paracetamol for the acute treatment of migraine, taking into account the person’s preference, comorbidities, and risk of adverse events.

In November 2015, this was an off-label use of triptans in under 18s. See NICE's information on prescribing medicines. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s.
 

When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.

In November 2015, this was an off-label use of triptans in under 18s. See NICE's information on prescribing medicines.
 

Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.

Do not offer ergots or opioids for the acute treatment of migraine.

For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated:

• consider a non-oral preparation of metoclopramide or prochlorperazine and

• if non-oral metoclopramide or prochlorperazine is used, consider adding a non-oral NSAID or triptan if they have not been tried.Note the special warnings and precautions for use in the summaries of product characteristics for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
  
  In November 2015, only a buccal preparation of prochlorperazine was licensed for this indication (prochlorperazine was licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people. See NICE's information on prescribing medicine

  
  

Treatment of Migraine During Pregnancy

• Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptan or an NSAID after discussing the woman’s need for treatment and the risks associated with the use of each medication during pregnancy.
  
  In November 2015, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. See NICE's information on prescribing medicines.
   

• Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy.

Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the person’s preference, comorbidities, risk of adverse events, and the impact of the headache on their quality of life.

For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:

• the potential benefit in reducing migraine recurrence and severity

• the risk of fetal malformations with topiramate

• the risk of reduced effectiveness of hormonal contraceptives with topiramate

• the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method).
  
  Follow the MHRA safety advice on antiepileptic drugs in pregnancy.
  
  In November 2015, this was an off-label use of topiramate in children and young people. See NICE's information on prescribing medicines.
  
  People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.

Consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities, and risk of adverse events.

In November 2015, this was an off-label use of amitriptyline. See NICE's information on prescribing medicines.

Do not offer gabapentin for the prophylactic treatment of migraine.

If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks according to the person's preference, comorbidities, and risk of adverse events.

For people who are already having treatment with another form of prophylaxis and whose migraine is well controlled, continue the current treatment as required.

Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.

Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.

In November 2015, this was an off-label use of riboflavin, but this is available as a food supplement.

Discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist.

Offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache.

In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.
 

When using oxygen for the acute treatment of cluster headache:

• use 100% oxygen at a flow rate of at least 12 litres per minute with a non-rebreathing mask and a reservoir bag and

• arrange provision of home and ambulatory oxygen.

When using a subcutaneous or nasal triptan, ensure the person is offered an adequate supply of triptans calculated according to their history of cluster bouts, based on the manufacturer’s maximum daily dose.

In November 2015, this was an off-label use of subcutaneous triptans in under 18s. Nasal triptans did not have a UK marketing authorisation for this indication. See NICE's information on prescribing medicines.
 

Do not offer paracetamol, NSAIDs, opioids, ergots, or oral triptans for the acute treatment of cluster headache

Consider verapamil for prophylactic treatment during a bout of cluster headache. If unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring.

In November 2015, this was an off-label use of verapamil. See NICE's information on prescribing medicines.
 

Seek specialist advice for cluster headache that does not respond to verapamil.

In November 2015, this was an off-label use of verapamil. See NICE's information on prescribing medicines.
 

Seek specialist advice if treatment for cluster headache is needed during pregnancy