1. The 60-Second Briefing

• Diagnose migraine clinically against the ICHD-3 criteria; do not arrange neuroimaging solely for reassurance.
• For an acute attack in an adult, offer combination therapy — an oral triptan plus an NSAID, or an oral triptan plus paracetamol; sumatriptan 50–100 mg is the first-choice triptan.
• Add an antiemetic (prochlorperazine 10 mg or metoclopramide 10 mg) even without nausea, because it improves analgesic absorption.
• Cap acute medication at 2 days per week; medication overuse headache is the single most common reason “treatment-resistant” migraine fails to settle.
• For any woman with migraine with aura on combined hormonal contraception, the method is UKMEC 4 — switch to a progestogen-only or non-hormonal method at the same consultation. Highest-yield AKT recall on this page.
• Before prescribing topiramate to a female of childbearing potential, complete the Pregnancy Prevention Programme (MHRA, June 2024) — Risk Awareness Form, negative pregnancy test, highly effective contraception.

 

2. Diagnosis

Migraine is a clinical diagnosis. ICHD-3 migraine without aura needs ≥5 attacks lasting 4–72 hours, with ≥2 of (unilateral, pulsating, moderate–severe, aggravated by routine activity) and ≥1 of (nausea/vomiting, photophobia, phonophobia). ICHD-3 migraine with aura needs ≥2 attacks of fully reversible visual, sensory, speech, motor, brainstem or retinal symptoms developing over ≥5 minutes and lasting 5–60 minutes, with headache within 60 minutes.

Episodic migraine occurs on <15 days/month; chronic migraine on ≥15 days/month with ≥8 days of migraine features for >3 months. Menstrual-related migraine occurs predominantly between 2 days before and 3 days after menstruation in ≥2 of 3 consecutive cycles, confirmed with an 8-week headache diary. Where any migraine features overlap with frequent tension-type headache, diagnose chronic migraine.

The two differentials trainees miss are tension-type headache and cluster headache.

Feature	Migraine	Tension-type	Cluster
Location	Unilateral or bilateral	Bilateral	Strictly unilateral, around/above the eye
Quality	Pulsating	Pressing, non-pulsating	Sharp, boring or burning
Intensity	Moderate or severe	Mild or moderate	Severe or very severe
Activity	Aggravated by routine activity	Not aggravated	Restlessness or agitation
Duration	4–72 hours	30 min to continuous	15–180 minutes

3. Red Flags and Urgent Action

• Thunderclap headache (maximum within 5 minutes) → emergency admission (subarachnoid haemorrhage, venous sinus thrombosis, dissection).
• Fever, neck stiffness, impaired consciousness, seizure → emergency admission (meningitis/encephalitis).
• New focal neurological deficit, personality change, papilloedema, or atypical aura (duration >60 minutes, motor weakness, double vision, monocular symptoms, poor balance) → same-day specialist assessment (stroke, space-occupying lesion).
• Aura occurring for the first time on combined hormonal contraception → treat as suspected stroke/TIA, not a contraceptive side effect.
• New-onset headache aged over 50 → urgent assessment (temporal arteritis with same-day specialist if features present; intracranial pathology).
• Headache worse on lying down, triggered by Valsalva, or progressive over days–weeks → urgent referral (space-occupying lesion, cerebral venous sinus thrombosis).
• New or different headache in pregnancy → same-day blood pressure and urinalysis (pre-eclampsia, cerebral venous thrombosis).
• Immunocompromise, or malignancy with brain metastatic potential (lung, breast, melanoma) → urgent referral.

 

4. Acute Management

If an adult presents with an acute attack, offer combination therapy — oral sumatriptan 50–100 mg with an NSAID (ibuprofen 400–600 mg, or naproxen) or with paracetamol 1000 mg — because combination is more effective than monotherapy, and naproxen’s longer half-life reduces recurrence. If monotherapy is preferred, an oral triptan, NSAID, aspirin 900 mg or paracetamol 1000 mg is acceptable.

If the person has aura, the triptan is taken at the start of the headache, not at the start of the aura (unless they coincide); triptans in the aura phase are less effective.

If a triptan is consistently ineffective, switch to a different triptan, because response varies between triptans within the same person.

If vomiting blocks oral treatment, switch to subcutaneous sumatriptan (3–6 mg, max 12 mg/24 h) or intranasal sumatriptan (10–20 mg, max 40 mg/24 h) — oral absorption fails once gastric stasis sets in. Orodispersible “melt” tablets are still gastrically absorbed.

Add an antiemetic — prochlorperazine 10 mg or metoclopramide 10 mg single dose — even without nausea, because it improves analgesic absorption. Metoclopramide is restricted to short-term use, maximum 5 days (MHRA, August 2013), because of acute dystonic reactions, particularly in young women.

Do not offer ergots or opioids — offer a non-oral triptan plus an antiemetic when the oral route is unavailable, because opioids worsen MOH and reduce future treatment response.

Rimegepant (an oral calcitonin gene-related peptide [CGRP] inhibitor) is an option if ≥2 triptans have not worked, or are contraindicated/not tolerated and NSAIDs and paracetamol have not worked (TA919, 2023).

Review acute treatment at 2–8 weeks.

 

5. Long-term / Preventive Management

Offer preventive treatment if attacks significantly impact quality of life (typically more than once a week, or prolonged and severe despite optimal acute treatment), acute treatments are contraindicated or ineffective, or the person is at risk of medication overuse headache. Exclude and treat MOH before starting prophylaxis — abrupt cessation of all overused acutes for ≥1 month, warning the person of transient worsening.

Option	Start	Titration	Maintenance / max	Avoid in	Safety flag	Alert
Propranolol	Lowest end of maintenance range, titrate to effect and tolerability	By response and tolerability	80–240 mg daily in divided doses	Asthma	Risk of harm from rapid deterioration in overdose; cautious supply in depression	HSSIB Potential under-recognised risk of harm from the use of propranolol (February 2020)
Topiramate	25 mg once daily at night for 1 week	Increase by 25 mg weekly	50–100 mg daily in 2 divided doses; max 200 mg/day	Pregnancy	Strictly contraindicated in pregnancy; reduces hormonal contraceptive efficacy; acute angle-closure glaucoma typically within first month	MHRA Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme (June 2024)
Amitriptyline	10–25 mg in the evening	By 10–25 mg every 3–7 days	25–75 mg in the evening (max per dose 75 mg)	Recent MI	Relatively high fatality rate in overdose	—

If asthma or obstructive airways disease, choose topiramate or amitriptyline, because propranolol may precipitate bronchospasm unresponsive to beta2-agonists.

If starting topiramate in a female of childbearing potential, enrol her on the Pregnancy Prevention Programme before the first prescription — negative pregnancy test, signed Risk Awareness Form, Patient Card, highly effective contraception (a copper IUD or LNG-IUS preferred; otherwise two complementary methods including a barrier, because topiramate reduces hormonal contraceptive efficacy). Review annually (MHRA, June 2024).

If there is depression or any overdose concern, prefer topiramate — both propranolol and amitriptyline carry significant overdose toxicity (HSSIB, February 2020).

If the person takes rizatriptan and you start propranolol, cap rizatriptan at 5 mg and do not co-administer within 2 hours.

If all three first-line options fail or are unsuitable, consider candesartan 16 mg daily (unlicensed; avoid in pregnancy), acupuncture (up to 10 sessions over 5–8 weeks), or sodium valproate (over 55 only). Riboflavin 400 mg once daily may help. Do not offer gabapentin. refer to neurology after three failed or unsuitable preventives — this opens specialist-initiated CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and oral CGRP agents (rimegepant, atogepant), with eligibility set by the relevant NICE technology appraisals; and, in chronic migraine with MOH addressed, botulinum toxin type A (TA260).

Review at 3–6 months. Failure is no response to the highest tolerated dose after 3 months. After 6–12 months of successful treatment, consider gradual withdrawal.

For predictable menstrual-related migraine unresponsive to standard acute treatment, consider mini-prophylaxis with frovatriptan 2.5 mg twice daily or zolmitriptan 2.5 mg twice or three times daily (both off-label), from 2 days before until 3 days after bleeding starts; the cycle must be regular.

 

6. Drug Safety, Interactions and Monitoring

Medicine	Contraindications	Cautions	Key interactions	Monitoring
Triptans (sumatriptan exemplar)	IHD, previous MI, coronary vasospasm, uncontrolled hypertension, peripheral vascular disease, previous TIA/CVA, severe hepatic impairment	CV risk factors (assess first), elderly (unlicensed >65), seizure history	Contraindicated with MAOIs (or within 2 weeks of stopping) and ergotamine; SSRI/SNRI, tramadol, fentanyl, lithium, St John’s wort — serotonin syndrome caution; rizatriptan + propranolol — cap 5 mg	Discontinue if heat, heaviness, pressure or tightness in throat/chest
Propranolol	Asthma, cardiogenic shock, marked bradycardia, heart block, peripheral vascular disease, heart failure, phaeochromocytoma	Diabetes (masks hypoglycaemia), myasthenia, hepatic/renal impairment, psoriasis	Avoid CCBs and antiarrhythmics; warfarin; rizatriptan (cap 5 mg)	Pulse and BP during titration; gradual withdrawal
Topiramate	Pregnancy (migraine prophylaxis — strictly contraindicated), acute porphyria, children	Metabolic acidosis risk; nephrolithiasis (hydration); halve dose if CrCl ≤70 mL/min	Reduces combined hormonal contraceptive efficacy; alcohol/CNS depressants; valproate (hyperammonaemia); warfarin (may reduce INR)	PPP review at initiation and annually; same-day ophthalmology for any acute visual change
Amitriptyline	Arrhythmias, heart block, manic phase of bipolar disorder, immediate post-MI	CV disease, epilepsy, prostatic hypertrophy, angle-closure glaucoma risk, suicide risk; elderly	MAOIs; QT-prolonging drugs; caution with other serotonergic drugs	Mood, anticholinergic effects; gradual withdrawal over ≥4 weeks
Candesartan (unlicensed)	Pregnancy, severe hepatic/cholestasis	Renal impairment, renal artery stenosis, valve stenosis, angioedema history	ACE inhibitors; aliskiren in diabetes/renal impairment	U&E and BP
Metoclopramide	GI haemorrhage/obstruction/perforation, recent GI surgery, phaeochromocytoma, epilepsy, Parkinson’s	Young adults 15–19 (acute dystonia), elderly, cardiac conduction disturbance	Levodopa/dopamine agonists; serotonergic drugs	Maximum 5 days (MHRA, August 2013)
Prochlorperazine	CNS depression, phaeochromocytoma, severe hepatic/renal dysfunction, Parkinson’s, narrow-angle glaucoma, myasthenia	Elderly, QT prolongation or heart failure (consider ECG), diabetes	QT-prolonging drugs, amitriptyline, antihypertensives	Drowsiness; do not drive on first doses

Additional alerts: topiramate Pregnancy Prevention Programme (MHRA, June 2024). NSAIDs are avoided after 20 weeks of pregnancy — premature ductus arteriosus closure and oligohydramnios. Sodium valproate is governed by a National Patient Safety Alert (paternal exposure within 3 months pre-conception is also regulated).

 

7. Special Groups

• Pregnancy — offer paracetamol first-line; if ineffective, consider sumatriptan (preferred triptan) or ibuprofen before 20 weeks only. Do not prescribe aspirin or opioids. Do not initiate prophylaxis in primary care.
• Breastfeeding — paracetamol first-line; sumatriptan if needed (manufacturer recommends withholding breastfeeding for 12 hours after a dose).
• Adolescents 12–17 — paracetamol or ibuprofen first-line; do not offer aspirin under age 16 (Reye’s syndrome) — offer paracetamol or ibuprofen instead. If simple analgesia fails, offer nasal sumatriptan 10 mg (the only triptan licensed in this age group). Antiemetics: prochlorperazine buccal 3–6 mg twice daily, or unlicensed metoclopramide. Do not initiate prophylaxis in primary care.
• Migraine with aura on combined hormonal contraception — UKMEC 4: stop the combined method at the same consultation and switch to a progestogen-only or non-hormonal method.
• New-onset migraine while on combined hormonal contraception — UKMEC 3: review the method and switch if any aura features are present.
• Established cardiovascular, cerebrovascular or peripheral vascular disease — triptans are contraindicated; offer NSAID or paracetamol monotherapy.
• Asthma or COPD — propranolol is contraindicated; choose topiramate or amitriptyline.
• Depression or established suicide risk — prefer topiramate; if amitriptyline is used, restrict the quantity supplied.
• Aged over 65 — triptans are not licensed; index of suspicion for secondary headache rises.

 

8. SCA Consultation Sketch

Patient (opener): “I’m getting awful headaches every couple of weeks — one side, throbs, I have to lie in the dark. The pill seems to make them worse. My mum had migraines, paracetamol never touched hers, so I’ve been taking my friend’s co-codamol. I’ve missed two shifts and my manager’s getting funny.”

Data-gathering priorities: features fitting migraine (unilateral, pulsating, photo/phonophobia, aggravation by activity); any aura, especially visual zigzags, sensory or speech symptoms — this changes the contraceptive plan; red flags (thunderclap, atypical aura, new headache different from usual); current contraception and pregnancy status; how often she is taking acute medication including the borrowed co-codamol (MOH risk); impact on work and mood.

GP framing the diagnosis: “What you’re describing sounds like migraine — attacks of one-sided throbbing headache with light or noise sensitivity. It’s a real condition but not a sign of anything dangerous in your brain. We don’t need a scan.”

GP on the difficult moment: “Two things to raise. The co-codamol — I understand why you tried it, but opioids make migraines worse over time, and taking painkillers more than a couple of days a week becomes part of the problem itself. I’d like to stop those and switch to proper migraine treatment. Second, because you’ve described visual zigzags before the headache, the combined pill isn’t safe for you any more — it raises stroke risk. I’d like to change you onto a different method today.”

Safety-net: “If you get a headache that comes on like a thunderclap — worst ever within seconds — or any weakness, slurred speech, or loss of vision in one eye, that’s a 999 call. Otherwise come back in 4–6 weeks, sooner if things are getting worse.”

 

9. When the Plan Changes

If: the person reports aura for the first time on combined hormonal contraception.

Why this changes the plan: the method is now UKMEC 4, and atypical aura is itself a stroke/TIA presentation.

What the GP does now: stop the combined method that day, arrange same-day specialist assessment, switch to a progestogen-only or non-hormonal method.

If: an established preventive has reached the highest tolerated dose with no response after 3 months.

Why this changes the plan: treatment has failed by the formal definition.

What the GP does now: confirm adherence, exclude MOH, switch to one of the remaining first-line options; refer to neurology after three failed preventives.

If: a patient on regular triptan or combination analgesic use returns with worsening daily headache.

Why this changes the plan: medication overuse headache is now active and will block any preventive working.

What the GP does now: advise abrupt cessation of all overused acutes for ≥1 month, warn of transient worsening, review.

If: a patient on topiramate develops sudden blurred or painful vision.

Why this changes the plan: acute myopia with secondary angle-closure glaucoma is a recognised topiramate adverse effect, typically within the first month.

What the GP does now: stop topiramate immediately and arrange same-day ophthalmology assessment.

10. Top AKT Pitfalls, Common Exam Angles and Self-Test

Pitfalls

• Treating frequent migraine by adding another triptan rather than counting acute medication days — cap acutes at 2 days/week and treat MOH when that ceiling is breached.
• Continuing the combined pill in migraine with aura because the migraines are mild — aura severity is irrelevant; aura makes combined hormonal contraception UKMEC 4.
• Prescribing topiramate to a woman of childbearing potential without enrolling her on the Pregnancy Prevention Programme — the PPP is a prerequisite, not a follow-up.
• Choosing propranolol in someone with depression because “beta-blocker is first-line” — overdose risk and the HSSIB alert (February 2020) make topiramate or amitriptyline preferable.
• Reassuring a patient over 50 with a new headache because “it sounds like migraine” — new-onset headache over 50 needs temporal arteritis and intracranial pathology excluded first.
• Continuing aspirin 900 mg acutely in a 14-year-old “because it worked for mum” — avoid aspirin under 16 (Reye’s); ibuprofen or paracetamol is the correct substitute.

 

Common Exam Angles

Angle: A 24-year-old woman attends for a combined-pill renewal. She has visual zigzags before her monthly migraines. Hidden challenge: the obvious default is to renew the pill or treat only the migraine; the contraceptive rule overrides. What the candidate must not miss: migraine with aura is UKMEC 4 — switch to a progestogen-only or non-hormonal method at the same consultation.

Angle: A 38-year-old woman has not tolerated propranolol; you are considering topiramate. Hidden challenge: two issues need addressing — choice of next preventive and the regulatory pre-requisite. What the candidate must not miss: enrol her on the Pregnancy Prevention Programme (MHRA, June 2024) before the first prescription.

Angle: A 14-year-old girl with episodic migraine. Her mother asks for “something stronger, like Migraleve with codeine.” Hidden challenge: the patient’s framing leads away from the right action. What the candidate must not miss: avoid aspirin under 16 (Reye’s) and opioids in migraine; offer ibuprofen or paracetamol, and nasal sumatriptan if simple analgesia fails.

Angle: A 56-year-old man presents with three episodes of unilateral throbbing headache with photophobia over 6 weeks; no prior history. Hidden challenge: the description fits migraine, but new-onset headache over 50 has a different pre-test probability. What the candidate must not miss: exclude temporal arteritis (urgent ESR/CRP) and intracranial pathology before diagnosing migraine.

 

Self-Test

Q1. A 29-year-old woman with a 6-month history of migraine without aura attends for acute treatment. Simple analgesia has been ineffective. She has no cardiovascular history and takes the progestogen-only pill. Which is the most appropriate first-line acute treatment?

A) Oral codeine 30 mg with paracetamol 1000 mg

B) Oral zolmitriptan 2.5 mg from 2 days before until 3 days after menstruation

C) Oral sumatriptan 50–100 mg combined with naproxen

D) Subcutaneous sumatriptan 6 mg

E) Refer to neurology

Answer: C. Combination of an oral triptan and an NSAID is first-line acute treatment; sumatriptan is first-choice triptan, with subcutaneous reserved for vomiting or oral failure (Section 4).

Q2. A 32-year-old woman uses a combined oral contraceptive pill. She presents with a 3-month history of headaches preceded by 20 minutes of flickering visual zigzags. Examination is normal between attacks. Which is the single most appropriate next step?

A) Reassure and continue current contraception

B) Stop the combined oral contraceptive and offer a progestogen-only or non-hormonal method

C) Start propranolol 80 mg twice daily for prevention

D) Arrange MRI brain

E) Refer to neurology to confirm the diagnosis

Answer: B. Migraine with aura is UKMEC 4 for combined hormonal contraception — stop the method and switch at the same consultation (Sections 5, 7).

Q3. A 41-year-old woman with episodic migraine has had no response to propranolol after 4 months at the highest tolerated dose. She has a 2-year-old child, is not currently planning further pregnancy, and uses condoms only. You are considering topiramate. Which is the most appropriate next step before issuing a prescription?

A) Issue topiramate 25 mg daily and review in 3 months

B) Issue topiramate together with the combined oral contraceptive pill

C) Refer to neurology for specialist initiation

D) Enrol her on the Pregnancy Prevention Programme — Risk Awareness Form, Patient Card, negative pregnancy test, highly effective contraception in place — then prescribe topiramate

E) Switch to amitriptyline as first-line instead

Answer: D. Topiramate is strictly contraindicated in pregnancy. The Pregnancy Prevention Programme (MHRA, June 2024) is mandatory before initiation in any female of childbearing potential; the combined pill alone is insufficient as topiramate reduces its efficacy (Sections 5, 6).

 

11. 90-Second Audio Recap

Diagnose migraine using ICHD-3. Without aura needs five attacks, four to seventy-two hours, with two of unilateral, pulsating, moderate to severe, or aggravated by activity, and one of nausea, light sensitivity or sound sensitivity. With aura, fully reversible visual, sensory or speech symptoms develop over at least five minutes and last five to sixty minutes.

For an acute attack in an adult, offer oral sumatriptan fifty to one hundred milligrams with an NSAID like naproxen, or with paracetamol. Add an antiemetic — prochlorperazine or metoclopramide — even without nausea. Take the triptan at the start of the headache, not the aura. If vomiting blocks the oral route, switch to subcutaneous or nasal sumatriptan. Do not use ergots or opioids.

Cap acute medication at two days a week, or suspect medication overuse headache.

For prevention, choose propranolol, topiramate or amitriptyline. Propranolol is contraindicated in asthma. Topiramate is contraindicated in pregnancy — never prescribe to a woman of childbearing potential without the Pregnancy Prevention Programme. In depression or overdose risk, prefer topiramate.

If your patient has migraine with aura and uses the combined pill, stop it the same day. Aura plus combined hormonal contraception is UKMEC four.

Review acute treatment at two to eight weeks, prevention at three to six months. Safety-net for thunderclap headache, weakness, slurred speech, or loss of vision in one eye.

.

References

Guidelines and Clinical Standards

Ahmed, F. (2019) National Headache Management System for Adults. British Association for the Study of Headache (BASH). Available at: https://www.bash.org.uk/ (Accessed: 26 May 2026).

Faculty of Sexual & Reproductive Healthcare (2016) UK Medical Eligibility Criteria for Contraceptive Use (UKMEC). London: FSRH. Available at: https://www.fsrh.org/standards-and-guidance/uk-medical-eligibility-criteria/ (Accessed: 26 May 2026).

Faculty of Sexual & Reproductive Healthcare (2019) FSRH Guideline: Combined Hormonal Contraception (amended October 2023). London: FSRH. Available at: https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/ (Accessed: 26 May 2026).

International Headache Society (2018) ‘The International Classification of Headache Disorders, 3rd edition (ICHD-3)’, Cephalalgia, 38(1), pp. 1–211. Available at: https://ichd-3.org/ (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2012, updated 2025) Headaches in over 12s: diagnosis and management. Clinical guideline CG150. London: NICE. Available at: https://www.nice.org.uk/guidance/cg150 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2012) Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. Technology appraisal guidance TA260. London: NICE. Available at: https://www.nice.org.uk/guidance/ta260 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2020) Galcanezumab for preventing migraine. Technology appraisal guidance TA659. London: NICE. Available at: https://www.nice.org.uk/guidance/ta659 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2021) Erenumab for preventing migraine. Technology appraisal guidance TA682. London: NICE. Available at: https://www.nice.org.uk/guidance/ta682 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2022) Fremanezumab for preventing migraine. Technology appraisal guidance TA764. London: NICE. Available at: https://www.nice.org.uk/guidance/ta764 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2023) Eptinezumab for preventing migraine. Technology appraisal guidance TA871. London: NICE. Available at: https://www.nice.org.uk/guidance/ta871 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2023) Rimegepant for preventing migraine. Technology appraisal guidance TA906. London: NICE. Available at: https://www.nice.org.uk/guidance/ta906 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2023) Rimegepant for treating migraine. Technology appraisal guidance TA919. London: NICE. Available at: https://www.nice.org.uk/guidance/ta919 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2024) Atogepant for preventing migraine. Technology appraisal guidance TA973. London: NICE. Available at: https://www.nice.org.uk/guidance/ta973 (Accessed: 26 May 2026).

National Institute for Health and Care Excellence (2019, updated 2023) Suspected neurological conditions: recognition and referral. NICE guideline NG127. London: NICE. Available at: https://www.nice.org.uk/guidance/ng127 (Accessed: 26 May 2026).

Scottish Intercollegiate Guidelines Network (2023) Pharmacological management of migraine (SIGN 155). Edinburgh: SIGN. Available at: https://www.sign.ac.uk/ (Accessed: 26 May 2026).

Drug Safety Alerts

Healthcare Safety Investigation Branch (2020) Potential under-recognised risk of harm from the use of propranolol. London: HSSIB. Available at: https://www.hssib.org.uk/patient-safety-investigations/potential-under-recognised-risk-of-harm-from-the-use-of-propranolol/ (Accessed: 26 May 2026).

Medicines and Healthcare products Regulatory Agency (2014) Metoclopramide: risk of neurological adverse effects — restricted dose and duration of use (originally issued August 2013). Drug Safety Update, 7(1), p. S2. Available at: https://www.gov.uk/drug-safety-update/metoclopramide-risk-of-neurological-adverse-effects (Accessed: 26 May 2026).

Medicines and Healthcare products Regulatory Agency (2023) Non-steroidal anti-inflammatory drugs (NSAIDs): potential risks following prolonged use after 20 weeks of pregnancy. Drug Safety Update, 16(11), p. 2. Available at: https://www.gov.uk/drug-safety-update/non-steroidal-anti-inflammatory-drugs-nsaids-potential-risks-following-prolonged-use-after-20-weeks-of-pregnancy (Accessed: 26 May 2026).

Medicines and Healthcare products Regulatory Agency (2024) Topiramate (Topamax): introduction of new safety measures, including a Pregnancy Prevention Programme. Drug Safety Update, 17(11), p. 1. Available at: https://www.gov.uk/drug-safety-update/topiramate-topamax-introduction-of-new-safety-measures-including-a-pregnancy-prevention-programme (Accessed: 26 May 2026).

Pharmacological References

Joint Formulary Committee (2024) British National Formulary. London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk/ (Accessed: 26 May 2026).

Paediatric Formulary Committee (2024) BNF for Children. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/ (Accessed: 26 May 2026).

Electronic Medicines Compendium (2025) Sumatriptan 100 mg tablets: Summary of Product Characteristics. Datapharm. Available at: https://www.medicines.org.uk/emc/product/525/smpc (Accessed: 26 May 2026).

Electronic Medicines Compendium (2025) Topiramate 25 mg film-coated tablets: Summary of Product Characteristics. Datapharm. Available at: https://www.medicines.org.uk/emc/product/100613/smpc (Accessed: 26 May 2026).

Electronic Medicines Compendium (2026) VYDURA 75 mg oral lyophilisate (rimegepant): Summary of Product Characteristics. Datapharm. Available at: https://www.medicines.org.uk/emc/product/13928/smpc (Accessed: 26 May 2026).

Electronic Medicines Compendium (2026) AQUIPTA 10 mg tablets (atogepant): Summary of Product Characteristics. Datapharm. Available at: https://www.medicines.org.uk/emc/product/15048/smpc (Accessed: 26 May 2026).

Nelson-Piercy, C. (2024) Handbook of Obstetric Medicine. 7th edn. Boca Raton: CRC Press.

Epidemiology, Burden and Risk

Dodick, D.W. (2018) ‘Migraine’, The Lancet, 391(10127), pp. 1315–1330.

Eigenbrodt, A.K. et al. (2021) ‘Diagnosis and management of migraine in ten steps’, Nature Reviews Neurology, 17(8), pp. 501–514.

Spector, J.T. et al. (2010) ‘Migraine headache and ischemic stroke risk: an updated meta-analysis’, American Journal of Medicine, 123(7), pp. 612–624.

Sacco, S. et al. (2013) ‘Migraine and hemorrhagic stroke: a meta-analysis’, Stroke, 44(11), pp. 3032–3038.

Vetvik, K.G. and MacGregor, E.A. (2017) ‘Sex differences in the epidemiology, clinical features, and pathophysiology of migraine’, The Lancet Neurology, 16(1), pp. 76–87.

Pregnancy, Lactation and Special Groups

UK Teratology Information Service (2023) Use of triptans in pregnancy. Newcastle upon Tyne: UKTIS. Available at: https://www.medicinesinpregnancy.org/ (Accessed: 26 May 2026).

National Library of Medicine (2018) LactMed: Drugs and Lactation Database. Bethesda, MD: NIH. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed: 26 May 2026).

Patient Information

NHS (2024) Migraine. Available at: https://www.nhs.uk/conditions/migraine/ (Accessed: 26 May 2026).

The Migraine Trust (2020) State of the migraine nation: dismissed for too long. London: The Migraine Trust. Available at: https://migrainetrust.org/ (Accessed: 26 May 2026).