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 Formulary Chapter 4: Central nervous system - Full Chapter
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04.07.04  Expand sub section  Antimigraine drugs
04.07.04.01  Expand sub section  Treatment of the acute migraine attack
 note 
  • New NICE guidance now recommends that combination treatment for acute migraine using a triptan plus an NSAID, or a triptan plus paracetamol are the most clinically and cost effective options for treatment of acute migraine offering a more rapid and prolonged benefit.
  • Oral sumatriptan has more evidence from randomised controlled trials to support its use than any other triptan although efficacy varies amongst individuals. Therefore prescribe triptans generically and start with the one with the lowest cost. If this is consistently ineffective, try one or more alternative triptans eg naratriptan, eletriptan, rizatriptan, frovatriptan and almotriptan. QIPP detail aid: TRIPTANS – choice of agent.
  • For women and girls with predictable menstrual-related migraine that does not respond adequately to standard acute treatment, consider treatment with zolmitriptan or frovatriptan on the days migraine is expected.
  • Giving an anti-emetic a few minutes before the analgesic can improve gastric motility and enhance absorption (even in the absence of nausea and vomiting) eg metoclopramide or domperidone. Prochlorperazine or domperidone suppositories are useful if vomiting has commenced.
  • If vomiting restricts oral triptan therapy despite an anti-emetic, zolmitriptan nasal spray is the preferred option as significantly more (30%) is absorbed through the nasal mucosa than sumatriptan nasal spray which is mostly absorbed in the GI tract. Oro- dispersible tablets dissolve on the tongue and are convenient to take but are absorbed in the GI tract and not the buccal mucosa.
  • A holistic approach should be adopted when treating migraine; lifestyle and behavioural triggers should be identified that increase the frequency of attacks resulting in over use of medication. This increases the risk of adverse effects and can also cause medication overuse headache. Information on prevention of over use headache can be found here.
  • Do not offer ergots or opioids for the acute treatment of migraine.
Sumatriptan (oral)
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First Choice
Green
Prescribe generically. In trials, oral sumatriptan 50mg and 100mg strengths showed similar onset, analgesic efficacy and tolerability but the response to the 50mg strength was less consistent.  
Zolmitriptan (oral)
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Second Choice
Green
Prescribe generically. 
   
Rizatriptan Wafers
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Restricted Drug Restricted
Green
Dissolves on the tongue without water, which is convenient to take and rapidly absorbed.
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
 
   
Sumatriptan (nasal spray and injection)
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Restricted Drug Restricted
Green
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
Nasal spray is less costly than injection.
 
   
Zolmitriptan (nasal spray)
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Restricted Drug Restricted
Green
Due to high cost, restricted preparations should be reserved for occasions where oral administration is problematic.
 
   
04.07.04.02  Expand sub section  Prophylaxis of migraine
 note 
  • Prophylaxis is recommended if attacks are frequent (one or more per fortnight).
  • Review need for continuing prophylaxis at 6 month intervals.
  • Current treatment with non formulary choices for prophylaxis may be continued in patients whose migraine is well controlled.
Propranolol immediate release
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First Choice
Green
Avoid abrupt withdrawal. 
Topiramate
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Second Choice
Green
More expensive than propranolol. Teratogenic-avoid in women of child bearing age. 
   
Amitriptyline
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Formulary
Green
Useful for mixed presentation headache.
Nortripyline is a less sedative alternative used by local specialists although there is no formal evidence of efficacy; it is more costly than amitriptyline.
Use with caution in the prison environment. 
   
Botulinum Toxin Type A
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Restricted Drug Restricted
Red
High Cost Medicine
Botulinum Toxin Type A in line with the NICE TA260
A request form should be completed, see link below.

Date of entry of decision to Formulary: September 2012
 
Link  Botulinum Toxin Order Form
Link  NICE TA 260: Botulinum toxin type A for the prevention of headaches in adults with chronic migraine.
   
Flunarizine (Sibelium)
 Track Changes
Unlicensed Drug Unlicensed
Red
Unlicensed medication for prophylaxis of migraine in adults. For initiation by secondary care specialist only.
To be used once other medications have been unsuccessful  
   
 ....
 Non Formulary Items
Erenumab  (Aimovig)

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Non Formulary
Black

Awaiting NICE TA publication

 
Fremanezumab  (Ajovy)

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Non Formulary
Black

Awaiting NICE TA publication

 
Galcanezumab  (Emgality)

View adult BNF View SPC online Track Changes
Non Formulary
Black

Awaiting NICE TA publication

 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Black

Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

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