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GPs should use triptans first-line for acute migraine, says NICE

GPs should prescribe a triptan, in combination with NSAIDs or paracetamol, first-line in patients with acute migraine, recommend NICE guidelines published today.

The guidance overturns current practice where tripans are reserved for use after patients have tried several other over-the-counter options such as aspirin and ibuprofen to treat acute migraine.

British Association for the Association of Headache guidelines from 2010 recommend a ‘treatment ladder' for acute migraine, with low-cost over-the-counter analgesics used first, and triptans reserved until stage three.

NICE also says there is ‘inadequate evidence' for the effectiveness of amitriptyline in the prophylaxis of migraine, again disagreeing with the BASH guidelines that recommend this option first-line to prevent migraine attacks.

It also recommends GPs advise patients with migraine that riboflavin (400 mg once a day) ‘may be effective in reducing migraine frequency and intensity for some people'.

It also recommends GPs ‘consider a course of up to 10 sessions of acupuncture over five to eight weeks for the prophylactic treatment of chronic tension-type headache'.

This comes after the Cochrane Collaboration published two reviews that said there was ‘consistent evidence' to show acupuncture provided additional benefit to routine care for patients with migraines and also recommended it as an option for patients with frequent bouts of tension-type headaches.

On medication overuse, the guidance warns GPs to be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for three months or more:

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

- paracetamol, aspirin or an NSAID, either alone or any combination, on 15 days per month or more

Professor Martin Underwood, a GP and professor of primary care research at Warwick Medical School, who chaired the guideline's development said: ‘I hope this guideline will improve awareness of medication overuse headache both in primary care and among the general public because prevention is simple and treatment is difficult.

 ‘Explaining to patients that they should abruptly stop their medication, knowing that their headache will get much worse for several weeks before it will improve, is not an easy consultation.'

Story updated 12:07am