Previous changes

August 2025 — minor update. Added prescribing section for candesartan. 

February 2025 — minor update. Renamed section on emerging treatments to calcitonin gene-related peptide inhibitor medications. 

November 2024 — minor update. Wording update to information regarding atogepant to align with NICE technology appraisal. 

September 2024 — minor update. Revised wording on typical migraine symptoms. 

August 2024 — minor update.  A typographical error has been corrected.

July 2024 — reviewed.  A literature search was conducted in June 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There have been minor structural changes to the topic. Changes to the recommendations include an update regarding the topiramate pregnancy prevention programme in alignment with guidance from the Medicines and Healthcare products Regulatory Agency, the addition of candesartan or sodium valproate as alternative preventative treatment options (including the relevant restrictions regarding pregnancy/reproduction), and a recommendation to seek specialist advice about anti-emetic use in pregnant and breastfeeding women.

April 2024 — minor update. Removed advice on standard dose riboflavin being a risk for teratogenesis in pregnancy.

September 2022  — minor update. Added adverse effects of uveitis, mydriasis, choroidal detachments, retinal pigment epithelial detachments, and macular striae to the drug information relating to topiramate following an update to the manufacturer's summary of product characteristics.

May 2021 — minor update. A recommendation that a discussion of the potential benefits and risks, and the importance of effective contraception for women and girls of childbearing potential when taking topiramate has been added to this topic in line with the updated NICE guideline Headaches in over 12s: diagnosis and management.

October 2020 — minor update. Dysphagia added as an adverse effect of triptans in line with the revised manufacturer's SPC.

July 2020 — minor update. The adverse effects of topiramate have been updated in line with the revised manufacturer's SPC.

April 2019 — reviewed. A literature search was conducted in March 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Minor changes to the recommendations have been made in line with updated guidance from the National Institute for Health and Care Excellence and the Scottish Intercollegiate Guidelines Network.

October 2018 — minor update. New product availability added.

February 2018 — minor update. SIGN (2018) Pharmacological management of migraine.

December 2017 — minor update. Added information about fetal malformations and effectiveness of hormonal contraceptives as an effect of topiramate.

September 2017 — minor update. Added information about hyperammonemia as an adverse effect of topiramate.

August 2017 — minor update. More accurately worded text in CG150, in the management section for 'Acute treatment of young people'.

May 2016 — minor update. Updated text to reflect the current advice from the Medicines and Healthcare products Regulatory Agency (MHRA) on domperidone.

October 2015 — minor update. Prescribing information has been updated to include intestinal ischemia as a possible adverse effect of almotriptan.

May 2014 — minor update. Update to the text to reflect recent advice issued by the European Medicines Agency regarding the dose and length of treatment with domperidone.

December 2013 — minor update. The link to the UKMI drugs in lactation website has been removed as this no longer exists.

September 2013 — minor update. Update to the text to reflect current recommendations regarding metoclopramide.

January to August 2013 — reviewed. A literature search was conducted in January 2013 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Recommendations from the guideline Headache - Diagnosis and management of headache in young people and adults commissioned by the National Institute for Health and Care Excellence (NICE) have been added.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

February 2012 — minor update. McNeil Products Ltd, in collaboration with the Medicines and Healthcare products Regulatory Agency (MHRA), has published new safety data regarding the association of domperidone with an increased risk of serious ventricular arrhythmias or sudden cardiac death. This topic has been updated to reflect their advice on dosing, adverse effects, and drug interactions.

July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency. Prescriptions have been updated to reflect the revised dosing. 

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

October 2010 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

March 2010 — minor update. Advice from the NICE guideline Depression in adults with a chronic physical health problem regarding drug interactions between antidepressants and triptans has been added. 

July to December 2008 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. The scope of this CKS topic has been expanded to cover the management of children with migraine. Prescriptions for topiramate have been removed as this would be initiated by a specialist.

September 2008 — minor correction to Changes section. 

July 2006 — updated. Topiramate is now licensed for the prophylaxis of migraine in adults and prescriptions have been added for use under specialist supervision. 

February 2006 — minor update. Black triangle removed from almotriptan.

November 2005 — minor technical update. 

July 2005 — updated text discussing nonsteroidal anti-inflammatory drugs (NSAIDs) in the Medicines management and Prescribing points sections.

January 2005 — rewritten. Validated in March 2005 and issued in April 2005.

December 2001 — rewritten. Validated in March 2002 and issued in April 2002.

September 1998 — written.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 June 2024.

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2024.

Systematic reviews and meta-analyses

• Karlsson, W.K., Ostinelli, E.G., Zhuang, Z.A., et al. (2024) Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis. BMJ. https://www.bmj.com [Free Full-text]
• Gargari, O. K., Aghajanian, S., Togha, M., et al. (2024). Preventive Medications in Pediatric Migraine: A Network Meta-Analysis. JAMA Network Open, 7(10), e2438666-e2438666. [Abstract]

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2024.

New policies

No new national policies or guidelines since 1 June 2024.

New safety alerts

No new safety alerts since 1 June 2024.

Changes in product availability

• New product Xytencorg (propranolol) 10 mg Orodispersible tablets. This new orodispersible formulation of propranolol, also available in a 40mg strength, is licensed for treatment of hypertension, angina, MI, cardiomyopathy, dysrhythmias, thyrotoxicosis, essential tremor, anxiety, and prophylaxis of upper GI bleeding and migraine. See more here.

Basis for recommendation

The information on clinical features and diagnostic criteria for migraine is based on clinical guidance from the National Institute for Health and Care Excellence (NICE) Headaches in over 12s: diagnosis and management [NICE, 2021], the Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition [IHS, 2018], British Association for the Study of Headache (BASH) National headache management system for adults [BASH, 2019], Sottish Intercollegiate Guidelines Network (SIGN) Pharmacological management of migraine [SIGN, 2023], Primary care management of headache in adults [Becker, 2015], a consensus statement from the Danish Headache Society, European Headache Federation and the European Academy of Neurology Diagnosis and management of migraine in ten steps [Eigenbrodt, 2021], and expert opinion in review articles [Schwedt, 2014; Dodick, 2018]  [Do, 2021; BMJ Best Practice 2023a].

Migraine characteristics

• Headache is the core feature which supports a diagnosis of migraine. Recurrent headaches that interfere with a person's ability to function are often migraines but the presence of additional migraine features should be queried [BMJ Best Practice 2023a].
• The characteristics typical of the various types, subtypes and sub forms of migraine are detailed by the Headache Classification Committee of the IHS [IHS, 2018].
  • For migraine without aura, the IHS recommends:
    • At least 5 attacks fulfilling the criteria  should be used for diagnosis purposes because fewer attacks may be difficult to distinguish from symptomatic migraine-like attacks and the nature or symptoms of attacks may be difficult for people to understand.
    • Where a person falls asleep during a migraine attack and wakes without symptoms, the duration of the attack is considered as the period from onset to awakening.
• Migraine headache is reported to be unilateral in 60% of cases, throbbing in 50%, and aggravated by physical activity in 90%. Headache can change sides during or between attacks [Dodick, 2018].
• In children and adolescents (aged under 18 years) bilateral headache occurs more often than in adults and is usually frontotemporal. Occipital headache in children is rare and alternative underlying causes should be considered [IHS, 2018].

Exclude other causes

• Although patients will have a primary headache disorder in most cases, serious secondary pathology should always be excluded [Do, 2021].
• Distinction from other primary headache disorders is also highly important for successful management, while distinction from secondary headache disorders is crucial because some of these disorders are serious and potentially life-threatening [Eigenbrodt, 2021].
• The International Classification of Headache Disorders (ICHD) diagnostic criteria specifies that ‘headache must not be better accounted for by another diagnosis’ – a thorough assessment must be carried out in all cases and the differential diagnoses considered [IHS, 2018].
• It is recognized that people can have more than one headache diagnosis, and that the diagnosis of migraine does not preclude the diagnosis of another headache disorder if criteria are met [BMJ Best Practice 2023a]. Therefore, patients may simultaneously have a primary headache disorder and new onset of a secondary cause, further emphasizing the need for a thorough investigation [Do, 2021].

Aura

• Aura is not unique to migraine, and can occur in other forms of primary headaches [BASH, 2019].
• Migraine with typical aura can include:
  • Visual and/or sensory and/or speech/language symptoms — visual aura is the most common type of aura and occurs in over 90% of people who have migraine with aura [IHS, 2018].
  • Sensory aura often presents with unilateral pins and needles and or numbness which gradually moves away from the point of origin on the body, face and/or tongue [IHS, 2018].
• The ICHD diagnostic criteria for migraine with typical aura does not include motor, brainstem or retinal symptoms [IHS, 2018]:
  • Motor symptoms are often longer lasting (up to 72 hours) than typical aura – other causes of symptoms (such as stroke) must be considered [IHS, 2018].
• Aura usually precedes, but may occur during, or after the headache [BASH, 2019].
• NICE [NICE, 2021] and Institute of Health Economics Alberta [Becker, 2015] recommend that referral/further investigations are considered in people presenting with atypical aura symptoms.
• The information on aura without migraine headache is from the ICHD diagnostic criteria for Typical aura without headache [IHS, 2018].

Chronic migraine

• Medication overuse occurs frequently with chronic migraine (up to 50% of patients with chronic migraine revert to episodic migraine after drug withdrawal) [IHS, 2018].
• Medication overuse headache can result from, and is perpetuated by, overuse of acute or symptomatic headache medications such as triptans, opioids, nonsteroidal anti-inflammatories (NSAIDs) and paracetamol. Simple analgesics (alone or in combination with caffeine) are the most frequently overused drugs followed by triptans [BMJ Best Practice 2023a].

Menstrual-related migraine

• Diagnostic criteria for menstrual-related migraine is from the NICE clinical guideline [NICE, 2021].

Basis for recommendation

The information on differential diagnoses for migraine is based on clinical guidance from the Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition , a consensus statement from the Danish Headache Society, European Headache Federation and the European [IHS, 2018]Academy of Neurology Diagnosis and management of migraine in ten steps [Eigenbrodt, 2021], and expert opinion in review articles [Schwedt, 2014; Charles, 2017; Dodick, 2018; BMJ Best Practice 2023a].

Primary headaches

• Tension-type headache is the only other paroxysmal headache disorder that is prevalent in the general population, but lacks some of the symptoms typically observed in migraine; usually involving bilateral, mild to moderate pain with a pressing or tightening quality which is not aggravated by routine physical activity [Eigenbrodt, 2021].
• Cluster headache is a much less prevalent primary headache disorder, affecting approximately 0.1% of the general population. Typical symptoms are considered highly characteristic and include frequent and recurrent short-lasting attacks (15 minutes to 3 hours) of severe or very severe intensity, which is strictly unilateral [Eigenbrodt, 2021].

What information and self-care advice should I give to person with migraine?

• Explain the diagnosis and provide information on migraine.
  • Patient information is available from:
    • NHS A-Z — Migraine.
    • The Migraine Trust — About migraine.
• Advise the person that:
  • Although migraine cannot be cured, it can be effectively managed in most cases.
  • Keeping a headache diary can be helpful in identifying triggers and monitoring the effectiveness of treatment.
    • For further information on headache diaries, see the CKS topic on Headache - assessment.
  • Avoidance of known triggers and lifestyle changes such as stress management, good sleep hygiene, adequate hydration, regular meals, exercise, mindfulness or relaxation techniques, and maintenance of a healthy weight can help.
    • Co-morbidities (such as sleep apnoea, insomnia, depression and anxiety) which may exacerbate migraine should be optimally treated — for further information, see the CKS topics on Depression, Generalized anxiety disorder, Insomnia, and Obstructive sleep apnoea syndrome.
  • Medication overuse headache (MOH) is common in people with migraine and can be avoided by restricting acute medication to a maximum of 2 days per week.
    
    • MOH can occur with 15 or more days per month use of simple analgesics (such as aspirin, ibuprofen and paracetamol) or 10 or more days use per month of triptans or combination analgesics.
    • For people with MOH, advise abrupt cessation of all overused simple analgesics and triptans for at least 1 month, and explain the potential for headache symptoms to worsen in the short term before they improve.
    • For more information, see the CKS topic on Headache - medication overuse.
• Ensure that women who have migraine with aura are not using combined hormonal contraception, as this is contraindicated.
  • For further information on contraceptive use and migraine, see the CKS topic on Contraception - assessment.

What acute treatment should I prescribe?

• Depending on the severity of attacks, associated symptoms, contraindications and comorbidities:
  • Offer simple analgesia such as:
    • Ibuprofen (400 mg) — if ineffective, consider increasing to 600 mg or
    • Aspirin (900 mg) or
    • Paracetamol (1000 mg).
      • These treatments should be used for 1 dose, and should be taken as soon as migraine symptoms develop.
  • Offer a triptan, alone or in combination with paracetamol or an NSAID:
    • Oral sumatriptan (50–100 mg) is the first choice — other triptans should be offered if sumatriptan fails.
    • Combination with an NSAID with a long half-life (such as naproxen) may be most effective.
    • If vomiting restricts oral treatment, consider a non-oral formulation (such as intra-nasal or subcutaneous).
    • For more information, please see the section on Prescribing information — Triptans.
  • Consider offering an anti-emetic (such as metoclopramide 10mg or prochlorperazine 10mg) in addition to other acute medication, even in the absence of nausea and vomiting.
    • Metoclopramide should not be used regularly due to the risk of extrapyramidal side effects.
    • For more information, please see the section on Prescribing information — Anti-emetics.
  • Rimegepant (an oral calcitonin gene-related peptide [CGRP] inhibitor placed on or under the tongue) is recommended as an option in NICE guidance for the acute treatment of migraine with or without aura in adults. Consider prescribing only if for previous migraines:
    • at least 2 triptans were tried and they did not work well enough or
    • triptans were contraindicated or not tolerated, and NSAIDs and paracetamol were tried but did not work well enough.
    • For more information, please see the section on Prescribing information — Rimegepant.
• Advise the person that:
  • Acute medication should be taken early while pain is mild.
  • If they have aura, triptans should be taken at the start of the headache and not at the start of the aura (unless the aura and headache start simultaneously).
  • Treatments which have not been effective 2 hours after use are unlikely to be effective for treating the attack, in such cases higher doses, where appropriate, or alternative simple analgesics or combination treatments should be considered.
• Do NOT offer ergots or opioids.
• Arrange follow up within 2–8 weeks.

How should I follow up an adult with migraine?

• Arrange follow up within 2–8 weeks of starting treatment. At review:
  • Discuss frequency of attacks, effectiveness of treatment, adverse effects and lifestyle improvements.
  • If treatment has been effective, is being used appropriately and is well tolerated, continue it (with appropriate medication reviews).
    • Advise the person to attend for review sooner if headache changes in nature or adverse effects develop.
  • If previous acute treatment has proven ineffective:
    • Reconfirm the diagnosis — consider the need for referral.
    • Consider alternative triptans (oral, nasal or subcutaneous), combination therapy with an oral triptan and an NSAID or an oral triptan and paracetamol, if not tried previously and no contraindications.
    • Consider Rimegepant as an option if the necessary criteria are met.
    • Consider the need for preventative therapy.
  • Reiterate advice on avoidance of medication overuse headache.

Preventive treatment

• For information on:
  • When to consider preventive treatment, see Criteria for preventive treatment.
  • What treatments are recommended for migraine prevention and how to follow up a person on preventative treatment, see Choice of preventative treatment and follow up.
  • What treatments are recommended for prevention of menstrual or menstrual-related migraine, see Preventive drugs for menstrual and menstrual-related migraine.

When should I refer a person with migraine?

• Consider admission or urgent referral if:
  • A serious cause of headache is suspected (see the section on Red flags in the CKS topic on Headache - assessment).
  • The person is in severe, uncontrolled status migrainosus (migraine lasting for more than 72 hours).
• Seek advice/refer to neurology (with urgency depending on the clinical situation) if:
  • A complication of migraine has developed.
  • Atypical symptoms (such as motor weakness or poor balance) are present.
  • The diagnosis of migraine is uncertain.
  • Optimal treatment in primary care does not adequately control the symptoms (medication overuse headache should be considered).

How should I assess a young person with migraine?

• Carry out a thorough history and examination as described in the CKS topic on Headache - assessment.
  • Be alert for clinical features suggestive of serious secondary headache disorders requiring emergency or urgent referral to secondary care (for further information, see the section on Red flags in the CKS topic on Headache - assessment).
  • Include questions relevant to young people such as:
    • Amount of time missed from school or college.
    • Possible causes of attacks — suspected triggers or emotional problems (for example, bullying or problems at home).
  • Consider other factors such as:
    • The child's general health between attacks.
    • The level of anxiety and concern migraines cause (for the child and parent).
    • The presence of more than one type of headache.
• A headache diary for a minimum of 8 weeks can be helpful in diagnosis, identifying triggers, frequency and severity of attacks and impact of treatment.
  • For more information on headache diaries, see the CKS topic on Headache - assessment.
• Be aware that the clinical features of migraine in children and adolescents may differ from those observed in adults:
  • The attacks may be comparatively shorter in duration.
  • Headaches may be bilateral and less often pulsating.
  • Gastrointestinal disturbances are commonly prominent.

How should I manage a young person with migraine?

• Provide the young person/carer with information and self-care advice.
  • Migraine in children often responds to conservative management with trigger avoidance and simple analgesia.
  • Encourage the use of a headache diary for a minimum of 8 weeks to help identify triggers (such as missed meals, dehydration and irregular sleep).
• For symptomatic relief of acute attacks in young people aged 12–17 years:
  • Offer simple analgesia such as paracetamol or a non-steroidal anti-inflammatory (NSAID) such as ibuprofen (if not contraindicated).
    • Do NOT offer aspirin to young people under 16 years of age because of the potential risk of Reye's syndrome.
    • For further information, see the CKS topic on Analgesia - mild-to-moderate pain and NSAIDS - prescribing issues.
  • If simple analgesia is ineffective consider a nasal triptan.
    • Oral triptans are not licensed for use in people under the age of 18 years.
  • If a nasal triptan is ineffective consider:
    • Combination therapy with a nasal triptan and an NSAID, or nasal triptan, and paracetamol.
    • Adding an anti-emetic such as metoclopramide (unlicensed) or prochlorperazine.
• Arrange follow up (within 1 month), but ask the child or carer to return sooner if symptoms worsen significantly or they have concerns in the meantime.
  • Treatment options are limited in children — have a low threshold for referral.
• Preventive treatment for children with migraine should not be initiated in primary care — seek specialist advice.

When should I refer a young person with migraine?

• Have a low threshold for seeking specialist advice/referral in young people with migraine.
  • Consider admission or urgent referral if:
    • A serious cause of headache is suspected — for more information, see the section on Red flags in the CKS topic on Headache - assessment.
    • The person is in severe, uncontrolled status migrainosus (migraine lasting for more than 72 hours).
  • Seek advice/refer to paediatrics (with urgency depending on the clinical situation) if:
    • Diagnosis of migraine is uncertain or atypical symptoms (such as motor weakness or poor balance) are present.
    • A complication of migraine has developed.
    • Optimal treatment in primary care does not adequately control symptoms (consider medication overuse headache).
    • Preventive treatment may be indicated.

How should I assess a woman with migraine who is pregnant or breastfeeding?

• Carry out a thorough history and examination as described in the CKS topic on Headache - assessment:
  • Be aware that new-onset migraine is rare in pregnant women, and pre-existing migraine usually improves.
  • Be alert for clinical features suggestive of serious secondary headache disorders requiring emergency or urgent referral to secondary care for further information, see the section on Red flags in the CKS topic on Headache - assessment).
  • Always check blood pressure and urinalysis in addition to neurological examination.
• For new-onset migraine:
  • It is essential to distinguish primary causes (such as migraine or tension headaches) from life-threatening secondary causes (such as pre-eclampsia and cerebral venous thrombosis).
  • Have a low threshold for seeking advice/referral.
• If the woman has a history of migraine:
  • Ensure that the characteristics of migraine before pregnancy and current migraine have not altered, and that the woman knows she must consult a health professional if headache is different from their usual migraine at any time pre or post-partum.
  • Review current and past medications which have been used to treat migraine, taking note of those which have not been effective or tolerated, to assess and address any safety concerns for the fetus or breastfeeding infant and to aid with developing a treatment plan for the perinatal period.
  • Have a low threshold for seeking advice/referral.

How should I manage a pregnant or breastfeeding woman with migraine?

• Provide information on migraine and self-care advice.
• Advise the woman that:
  • Migraine often improves in pregnancy, typically during the second and third trimesters.
  • Use of a headache diary can help identify triggers (such as lack of sleep, missed meals, and dehydration).
• Where possible, try non-pharmacological measures (such as avoidance of triggers, relaxation techniques and cognitive behavioural therapy) before considering drug therapy.
  • Many drugs are contraindicated or have limited evidence of safety in pregnancy and breastfeeding.
  • If drug treatment is being considered, the woman must be made aware of both the benefits and the risks associated with each medication.
• If drug treatment is essential, depending on contraindications and comorbidities:
  • Offer paracetamol first-line for the acute treatment of migraine in pregnancy and breastfeeding.
  • Consider ibuprofen (prior to 20 weeks gestational age only) or a triptan if paracetamol is ineffective.
    • There is less evidence of safety for nonsteroidal anti-inflammatories (NSAIDs) and triptans than for paracetamol.
    • NSAIDs should be avoided after 20 weeks gestational age due to the risk of premature closure of the ductus arteriosus and oligohydramnios — refer to obstetrics where use exceeds a period of several concurrent days.
    • Sumatriptan is the preferred triptan in pregnancy and breastfeeding — seek specialist advice if unsure or the infant is pre-term, of low birth weight, or has other medical problems.
  • Metoclopramide and prochlorperazine are used as short-term treatment options for nausea and vomiting in pregnancy, and metoclopramide may occasionally be used in breastfeeding — seek specialist advice if gastrointestinal disturbances are prominent migraine features in pregnant or breastfeeding women.
  • Do NOT prescribe aspirin or opiates for migraine in pregnant or breastfeeding women.
  • Recommend drug treatment should be used at the lowest effective dose for the shortest duration possible to achieve symptom control. 
• Arrange follow up (within 1 month), but ask the woman to seek urgent medical review sooner if they develop a headache that is different from their usual migraine or symptoms worsen.
  • Treatment options are limited in pregnancy — have a low threshold for referral.
• Do NOT initiate preventive treatment in primary care for women who are pregnant or breastfeeding — seek specialist advice.

When should I refer a pregnant or breastfeeding woman?

• Have a low threshold for seeking specialist advice or referring pregnant or breastfeeding woman with migraine as:
  • There is an increased risk of serious secondary causes of headache.
  • Treatment options for migraine in pregnancy and breastfeeding are limited.
• Consider admission or urgent referral if:
  • A serious cause of headache is suspected (for further information, see the section on Red flags in the CKS topic on Headache - assessment).
  • The person is in severe, uncontrolled status migrainosus (migraine lasting for more than 72 hours).
• Seek advice/refer to neurology (with urgency depending on the clinical situation) if:
  • A complication of migraine has developed (for example migraine has become chronic).
  • Atypical symptoms (such as motor weakness or poor balance) are present.
  • The diagnosis of migraine is uncertain.
  • Optimal treatment in primary care does not adequately control the symptoms (medication overuse headache should be considered).

Paracetamol

• For detailed prescribing information on paracetamol, see the CKS topic on Analgesia - mild-to-moderate pain.

Nonsteroidal anti-inflammatories

• For detailed prescribing information on nonsteroidal anti-inflammatory drugs (NSAIDs), see the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues.

Aspirin

• For detailed prescribing information on aspirin, see the CKS topics on Analgesia - mild-to-moderate pain.

Triptans

• The Scottish Intercollegiate Guidelines Network (SIGN) recommend sumatriptan (50–100 mg) as first choice of triptan in acute migraine for most people.
  • An alternative triptan should be tried if initial choice proves ineffective.
  • Other triptans available for treating migraine include almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, and zolmitriptan.
  • The British Association for the Study of Headache (BASH) guidelines highlight that in comparison with sumatriptan 100 mg alternative tripans may have:
    • Lower risk of adverse events — almotriptan (12.5 mg), frovatriptan (2.5 mg), and naratriptan (2.5 mg).
    • Improved 2-hour pain response — almotriptan (12.5 mg), eletriptan (80 mg), and rizatriptan (10 mg).
    • Lower recurrence rate — eletriptan (40 mg), and frovatriptan (2.5 mg).
• If vomiting restricts oral treatment, a non-oral formulation, such as intranasal spray or subcutaneous injection should be considered.
  • ‘Melt' preparations which dissolve in the mouth are gastrically absorbed and not categorised as non-oral preparations.
• Sumatriptan nasal spray (10mg) is the only triptan licensed for use in young people aged 12 years or older.
  • The manufacturer advises that use of sumatriptan in adolescents should be on the recommendation of a specialist or physician with significant experience in treating migraine, taking into account local guidance.
• Triptans are not licensed for people aged over 65 years.

Contraindications and cautions

• Do not prescribe triptans to people:
  • With cardiovascular disorders including ischaemic heart disease, hypertension (mild uncontrolled or controlled moderate or severe), previous myocardial infarction, coronary vasospasm (Prinzmetal's angina), arrhythmias, or peripheral vascular disease.
  • With cerebrovascular disorders including previous transient ischaemic attack or cerebrovascular accident.
  • With severe hepatic impairment.
  • Concurrently with other triptans, monoamine oxidase inhibitors or ergotamine (or its derivatives).
• Prescribe with caution in people:
  • With risk factors for cardiovascular disease — cardiovascular assessment required prior to prescription.
  • Who are elderly (unlicensed).
  • With a history of, or risk factors for, seizures.
  • With renal or hepatic impairment — dose adjustment may be required.
  • With mild controlled hypertension — transient increases in blood pressure and peripheral vascular resistance have been observed in a small proportion of users. 

Adverse effects

• Adverse effects include:
  • Nervous system disorders — dizziness and drowsiness.
  • Respiratory disorders — dyspnoea.
  • Gastrointestinal disorders — nausea and vomiting, dysphagia. Intestinal ischemia has been reported with almotriptan.
  • Skin and musculoskeletal disorders — myalgia.
  • Other general adverse effects — flushing, fatigue or weakness, feeling abnormal, pain and sensations of heat or cold.
  • With intranasal use — epistaxis, nasal irritation, altered taste and throat irritation.
  • With subcutaneous use — haemorrhage, skin reactions and swelling.
• Advise the person to seek medical advice and discontinue if symptoms of heat, heaviness, pressure or tightness (including throat and chest) occur.
• Drowsiness may affect performance of skilled tasks (such as driving).

Drug interactions

• Concomitant use is contraindicated with:
  • Monoamine oxidase inhibitors, or within 2 weeks of stopping a monoamine oxidase inhibitor.
  • Ergotamine or derivatives of ergotamine, including methysergide — increased risk of vasoconstriction.
  • CYP3A4 inhibitors (such as clarithromycin, erythromycin, ketoconazole, itraconazole, indinavir, nelfinavir, ritonavir) for eletriptan.
  • Other triptans — manufacturer advises waiting at least 24 hours following the use of one triptan before changing to an alternative triptan.
• Triptans should be used with caution in people taking selective serotonin reuptake inhibitors (SSRIs), selective noradrenaline reuptake inhibitors (SNRIs), clomipramine, dexamfetamine/lisdexamfetamine, fentanyl, granisertron, methadone, lithium, sibutramine, ondansetron, palonosetron, tramadol, trazodone, vortioxetine or St John's wort (because of the small risk of serotonin syndrome).
• The maximum dose of rizatriptan in people who are also taking propranolol should be 5 mg due to the risk of interactions — rizatriptan should not be taken within two hours of taking propranolol.

Pregnancy and breastfeeding

• Pregnancy
  • There is limited experience of using triptans during pregnancy.
  • Manufacturer recommends avoiding unless the potential benefit outweighs risk.
• Breast feeding
  • Present in milk but amount probably too small to be harmful.
  • Manufacturer recommends minimising infant exposure by avoiding breast feeding for 12 hours after treatment, during which time any breast milk expressed should be discarded.
• For more information about triptan use in pregnancy and breastfeeding, please see How should I manage a pregnant or breastfeeding woman with migraine?

[BASH, 2019; NICE, 2021; EMC, 2023a; EMC, 2023b]  [SIGN, 2023; BNF, 2024; EMC, 2024a]

What should I be aware of before prescribing metoclopramide or prochlorperazine?

Clinical guidelines from the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the British Association for the Study of Headache (BASH) state that metoclopramide (10 mg) or prochlorperazine (10 mg) can be considered in the treatment of migraine associated headache, nausea or vomiting.

• Metoclopramide
  • Metoclopramide is used in the treatment of acute migraine, but is not licensed for this indication.
  • Metoclopramide should not be used regularly due to the risk of extrapyramidal side effects and only be prescribed for short-term use, up to 5 days. 
• Prochlorperazine
  • Prochlorperazine is used in the treatment of acute migraine, but is not licensed for this indication.
  • Prochlorperazine as a buccal tablet can be used for nausea and vomiting in previously diagnosed migraine in people aged over 12 years.

Contraindications

• Do not prescribe metoclopramide to people with:
  • Gastrointestinal haemorrhage, obstruction, perforation or recent gastrointestinal surgery (3-4 days).
  • Phaeochromocytoma — risk of severe hypertension.
  • Neurological disorders such as epilepsy and Parkinson’s disease.
• Do not prescribe prochlorperazine to people with:
  • CNS depression.
  • Phaeochromocytoma.
  • Liver or renal dysfunction.
  • Neurological disorders such as epilepsy and Parkinson’s disease.
  • Cardiovascular disorders such as QT prolongation or heart failure — consider ECG; prochlorperazine use may potentiate QT interval prolongation and increase the risk of serious ventricular arrhythmias.
  • Myasthenia gravis.
  • Prostate hypertrophy.
  • Narrow angle glaucoma or agranulocytosis.

Cautions

• Prescribe metoclopramide with caution in
  • Children, young adults (15–19 years old) and the elderly.
  • Renal or hepatic impairment.
  • Cardiac disorders such as cardiac conduction disturbances, uncorrected electrolyte imbalance and bradycardia.
• Prescribe prochlorperazine with caution in:
  • The elderly.
  • People with hypothyroidism.
  • People with hypotension.
  • People with cardiovascular risk factors.
  • People with diabetes mellitus or risk factors for diabetes — hyperglycaemia or intolerance to glucose had been reported in patients treated with antipsychotic phenothiazines

Adverse effects

• Metoclopramide
  • Metoclopramide can induce acute dystonic reactions (facial and skeletal muscle spasms and oculogyric crises) — more common in younger people (especially girls and young women) and the very old.
  • Common adverse effects include diarrhoea, asthenia, drowsiness, depression, hypotension and menstrual cycle irregularities.
• Prochlorperazine
  • Prochlorperazine can cause sedation and extrapyramidal adverse effects (especially dystonia) — likely to be mild with occasional low-dose use.
    • Warn the person about drowsiness during the early days of treatment and advised not to drive or operate machinery.
  • Other adverse effects include blood disorders, endocrine disorders, insomnia and agitation, hyponatraemia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), skin reactions, cardiac disorders, jaundice, muscle rigidity, nasal congestion and respiratory depression.
    • Neuroleptic malignant syndrome (hyperthermia, rigidity, autonomic dysfunction and altered consciousness) may occur with any neuroleptic drug.

Drug interactions

• Metoclopramide
  • Levodopa or dopaminergic agonists — may reduce effectiveness.
  • Alcohol — potentiates the sedative effect of metoclopramide.
  • Central nervous system depressants (such as morphine derivatives, anxiolytics, sedative antihistamines, sedative antidepressants, barbiturates, clonidine) — sedative effects potentiated.
  • Serotonergic drugs — may increase the risk of serotonin syndrome.
• Prochlorperazine
  • Alcohol — increased risk of hypotension and CNS depression.
  • Amitriptyline — increased risk of hypotension.
  • Anti-hypertensives — increased risk of hypotension.
  • CNS depressants — may affect the ability to perform skilled tasks.
  • Cabergoline, levodopa and ropinirole — may reduce effectiveness.
  • QT prolonging drugs — increased risk of arrhythmias.
  • Carbamazepine and other drugs with myelosuppressive potential — increased risk of agranulocytosis.

Pregnancy and breastfeeding

• Pregnancy
  • Metoclopramide — not known to be harmful.
    • Manufacturer recommends avoid at the end of pregnancy as extrapyramidal syndrome in newborn cannot be excluded.
    • The Royal College of Obstetricians and Gynecologists (RCOG) recommend metoclopramide as a second line treatment option for nausea and vomiting in pregnancy due to the risk of extrapyramidal effects.
    • For further information, see the CKS topic on Nausea/vomiting in pregnancy.
  • Prochlorperazine
    • Although limited safety data are available, the RCOG recommend prochlorperazine as a first line treatment option for nausea and vomiting in pregnancy.
    • Extrapyramidal effects and withdrawal syndrome have been reported occasionally in the neonate when antipsychotic drugs are taken during the third trimester of pregnancy.
    • Manufacturer advises avoid unless benefits outweigh risks.
• Breastfeeding
  • Metoclopramide
    • Small amount present in breast milk.
    • Limited safety data available.
    • Manufacturer recommends avoid.
  • Prochlorperazine.
    • Based on levels of excretion for other phenothiazine derivatives, minimal amounts are expected in breast milk.
    • Limited data available, animal studies indicate possible adverse effects of antipsychotic medicines on the developing nervous system.
    • Manufacturer recommends avoid.

[LactMed, 2018; BASH, 2019; NICE, 2021; EMC, 2022a; SIGN, 2023; BNF, 2024; Nelson-Piercy, 2024; EMC, 2024b]

Rimegepant

The recommended dose is 75 mg rimegepant, as needed, once daily. The medication should be placed on the tongue or under the tongue. It will disintegrate in the mouth and can be taken without liquid.

Rimegepant is only licensed for adult use.

Patients should be advised to use dry hands when opening the blister and referred to the package leaflet for complete instructions.

Hypersensitivity reactions, including dyspnoea and rash, have occurred in less than 1% of patients treated with rimegepant in clinical studies. Some hypersensitivity reactions can occur days after administration. 

Contraindications and cautions

• Do not prescribe rimegepant to people with:
  • Previous hypersensitivity to rimegepant.
  • Severe hepatic impairment.
  • End-stage renal disease (CLcr < 15 ml/min).
  • Medication overuse headache (MOH).

Interactions

• Prescribe with caution:
  • Concomitant use with strong inhibitors of CYP3A4 —  such as clarithromycin, itraconazole, ritonavir, diltiazem, erythromycin, fluconazole.
    • These will increase the plasma concentration of rimegepant.
  • Concomitant use with strong or moderate inducers of CYP3A4 —  such as phenobarbital, rifampicin, St John's wort, modafinil.
    • These will reduce the plasma concentration of rimegepant.
    • The effect of CYP3A4 induction may last for up to 2 weeks after discontinuation of the strong or moderate CYP3A4 inducer.
  • Concomitant use with P-gp and BCRP only inhibitors —  such as cyclosporine, verapamil, quinidine.
    • Inhibitors of P‑gp and BCRP efflux transporters may increase plasma concentrations of rimegepant. Another dose within 48 hours should be avoided when it is concomitantly administered with strong inhibitors of P‑gp.

Pregnancy and breast feeding

• It is preferable to avoid the use of Rimegepant during pregnancy.
• Minimal concentrations of rimegepant are observed in breast milk. The amounts of CRGP inhibitors found in breast milk are minimal. However, evidence is limited and the developmental and health benefits of breast-feeding should be considered along with the mother's clinical need for the CGRP inhibitor and any potential adverse reactions on the breastfed infant from the medication.

Adverse effects

According to the manufacturer's SPC the most common adverse reaction is nausea for acute treatment (1.2%). Most of the reactions were mild or moderate in severity. Hypersensitivity, including dyspnoea and severe rash, occurred in less than 1% of patients treated.

[NICE, 2023a; NICE, 2025e; BNF, 2026; EMC, 2026; Preston, 2026]

Propranolol

• Clinical guidelines from the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the British Association for the Study of Headache (BASH) recommend propranolol for the prevention of migraine.

Cautions and contraindications

• Do not prescribe propranolol to people with:
  • Asthma or obstructive airways disease — may precipitate bronchospasm that is unresponsive to beta2-agonists.
  • Cardiovascular disorders such as cardiogenic shock, hypotension, marked bradycardia, heart block, coronary vasospasm (Prinzmetal's angina), peripheral vascular disease and heart failure.
  • Phaeochromocytoma.
• Prescribe propranolol with caution in people with:
  • Diabetes — may alter blood glucose levels and response to hypoglycaemia.
  • Myasthenia gravis
  • Hepatic and renal impairment.
  • History of anaphylaxis.
  • Psoriasis.
• Propranolol use may mask symptoms of hypoglycaemia and thyrotoxicosis.

Adverse effects

• Adverse effects include:
  • Metabolic and endocrine disorders — may cause hypoglycaemia (even in nondiabetics).
  • Nervous system disorders — dizziness, headache, paraesthesia, confusion and very rarely myasthenia gravis like syndrome.
  • Psychiatric disorders — sleep disturbances, nightmares, and depression.
  • Eye disorders — dry eye and visual disturbances.
  • Cardiovascular disorders — bradycardia, heart failure, peripheral vascular disease, hypotension, cold extremities, and Raynaud's syndrome.
  • Respiratory disorders — bronchospasm and dyspnoea.
  • Gastrointestinal disorders — diarrhoea, nausea, vomiting, constipation and dry mouth.
  • Skin disorders — alopecia, exacerbation of psoriasis, and rash.
  • Genitourinary disorders — sexual dysfunction.
  • General disorders — fatigue and lassitude.

Drug interactions

• Calcium channel blockers and anti-arrhythmic drugs — avoid, may result in severe hypotension, bradycardia and cardiac failure.
• Anti-coagulants — may increase plasma concentration of warfarin.
• Antidiabetic drugs — modifies response to hypoglycaemia.
• Antihypertensive drugs — may result in an enhanced hypotensive effect.
• Methyldopa and levodopa — may result in an enhanced hypotensive effect.
• Ergotamine or related compounds — vasospastic reactions have been reported.
• Sympathomimetics — may counteract the effect of beta-blockers.
• The maximum dose of rizatriptan in people who are also taking propranolol should be 5 mg due to the risk of interactions — rizatriptan should not be taken within two hours of taking propranolol.

Pregnancy and breastfeeding

• Pregnancy
  • Avoid — beta-blockers may cause intra-uterine growth restriction, neonatal hypoglycaemia, and bradycardia.
  • Manufacturer advises that propranolol should not be given in pregnancy unless essential.
• Breast feeding
  • Amount present in breast milk likely too small to affect infants however there is a risk of possible toxicity due to beta-blockade.
  • Manufacturer advises that propranolol should not be given in lactation unless essential.

[BASH, 2019; NICE, 2021; EMC, 2022; SIGN, 2023]

Topiramate

• Clinical guidelines from the National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN) and the British Association for the Study of Headache (BASH) recommend topiramate for the prevention of migraine.
• Topiramate should be initiated at a low dose and titrated slowly.
• Topiramate is strictly contraindicated in pregnancy.
  • Topiramate should not be used in women of child-bearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled, including using highly effective contraception, providing a negative pregnancy test to exclude pregnancy before starting topiramate, and being fully aware of the risks associated with topiramate in pregnancy.
  • Women should be advised to seek further advice on migraine prophylaxis if planning a pregnancy.

Cautions and contraindications

• Do not prescribe topiramate in:
  • Pregnancy — increased risk of fetal malformations.
  • Children.
  • Acute porphyria.
• Topiramate should be prescribed with caution in:
  • Women of child-bearing potential — a highly effective method of contraception is required as topiramate can impair the effectiveness of hormonal contraceptives. Pregnancy test advised before initiation. Explanation of the fetal and longer-term childhood developmental risks.
  • Breastfeeding — adverse effects reported in breastfed newborns/infants of treated mothers (seek specialist advice).
  • People at risk of metabolic acidosis.
  • People at risk of nephrolithiasis — ensure adequate hydration (particularly when undertaking strenuous activity or in a warm environment).
  • Hepatic and renal impairment — clearance of topiramate may be decreased.

Adverse effects

• Adverse effects include:
  • Nervous system disorders — cognitive impairment, confusion, dizziness, drowsiness, seizures, tremor, abnormal coordination, speech impairment, and abnormal sensation.
  • Psychiatric disorders — anxiety, depression, suicidal ideation/behaviour, mood swings and sleep disorders.
  • Respiratory disorders — cough, and dyspnoea.
  • Gastrointestinal disorders — gastrointestinal discomfort, constipation, diarrhoea, vomiting, dry mouth, nausea, anorexia and altered taste.
  • Renal disorders — nephrolithiasis.
  • Skin disorders — alopecia, decreased sweating, pruritus, and rash.
  • Eye disorders — topiramate has been associated with acute myopia with secondary angle closure glaucoma, uveitis, mydriasis, choroidal detachments, retinal pigment epithelial detachments, and macular striae. 
  • Metabolic disorders — metabolic acidosis.
    • Hyperammonemia with or without encephalopathy has been reported with topiramate treatment.
    • The risk is dose-related, and appears to be more frequent when topiramate is used concomitantly with valproic acid.
    • In patients who develop unexplained lethargy or changes in mental status associated with topiramate monotherapy or adjunctive therapy, it is recommended to consider hyperammonemic encephalopathy and to measure serum ammonia levels.
  • Musculoskeletal disorders — joint disorders, and muscle weakness.
  • Haematological disorders — anaemia.
  • Malaise.

Drug interactions

• Alcohol or other central nervous system (CNS) depressants — may have an additive effect. 
• Oral contraceptives — decreases the efficacy of combined hormonal contraceptives.
• Carbamazepine, phenytoin and valproate — increased risk of toxicity.
• Zonisamide — increases the risk of overheating and dehydration. Manufacturer advises avoid in children.
• Warfarin — may lead to decreased prothrombin time/international normalized ratio (INR).

Pregnancy and breastfeeding

• Topiramate is contraindicated in pregnancy
  • Topiramate should not be used in pregnancy nor in women of childbearing potential unless the conditions of a Pregnancy Prevention Programme are fulfilled.
  • Women of child-bearing potential should be fully informed of the risks related to the use of topiramate during pregnancy (major congenital malformation, low birth weight and neurodevelopmental impairment including intellectual disability, autistic spectrum disorder and attention deficit hyperactivity disorder).
  • A highly effective contraceptive method is advised in women of child-bearing potential — a pregnancy test should be performed before initiation of treatment. To prevent inadvertent exposure to topiramate during pregnancy, the Medicines and Healthcare products Regulatory Agency (MHRA) recommend:
    • User independent, long-acting, reversible contraceptives (such as a copper intrauterine device or a levonorgestrel intrauterine system), or alternatively,
    • Two complementary forms of contraception including a barrier method (whilst considering the potential for topiramate use to decrease the efficacy of systemic hormonal contraceptives). 
  • Further guidance has been produced by the MHRA, including a patient guide, a healthcare professional guide, and a risk awareness form to aid discussions around pregnancy prevention for women of child-bearing potential using topiramate.
• Topiramate should be avoided in breastfeeding
  • Topiramate is present in breast milk — adverse effects including diarrhoea, drowsiness, irritability and inadequate weight gain have been reported in breastfed newborns/infants of treated mothers.
  • Manufacturer recommends that decision to suspend breastfeeding or to discontinue/ abstain from topiramate therapy must be made taking into account the benefit of breastfeeding for the child and the benefit of topiramate therapy for the woman.

[BASH, 2019; NICE, 2021; SIGN, 2023; BNF, 2024; EMC, 2024c; MHRA, 2024]

Amitriptyline

• For detailed prescribing information on amitriptyline, see the CKS topic on Depression.
  • The dose range specified for amitriptyline for the indication of migraine prophylaxis in adults in the BNF and the Summary of Product Characteristics is 25-75 mg at night.
  • SIGN guidance states that amitriptyline (25–150 mg at night, target dose 30–50 mg) can be considered as a prophylactic treatment for patients with episodic or chronic migraine.
  • NICE guidance states that amitriptyline can be considered for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events — no dose range is specified.

[NICE, 2021; SIGN, 2023; EMC, 2023c; BNF, 2024]

Candesartan

Candesartan 16mg can be prescribed for migraine prophylaxis, but this is an unlicensed indication. 

Cautions and contraindications

• Do not prescribe candesartan to people with:
  • People who are pregnant. 
  • Severe hepatic impairment and/or cholestasis. 
• Prescribe candesartan with caution in people with:
  • Renal impairment.
  • Aortic or mitral valve stenosis.
  • Hypertrophic cardiomyopathy. 
  • A history of angioedema. 
  • Primary aldosteronism. 
  • Renal artery stenosis. 
• A lower starting dose is also recommended in elderly people. 
• For elderly people with hyperkalaemia or persistent postural hypotension candesartan may be inappropriate. 

Adverse effects

• Common adverse effects include:
  • Abdominal pain.
  • Back pain.
  • Cough.
  • Diarrhoea.
  • Dizziness.
  • Fatigue. 
  • Headache.
  • Hyperkalaemia.
  • Hypotension.
  • Increased risk of infection. 
  • Vertigo.
  • Vomiting.
  • Angiodema, myalgia, thrombocytopaenia, agranulocytosis, and skin reactions are also less common adverse effects. 

Drug interactions

• The concomitant use of candesartan and aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR less than 60ml/min/1.73m²
• Combination with ACE inhibitors increases the risk of hypotension, hyperkalaemia, and decreased renal function (manufacturers recommend specialist initiation and monitoring). 

Pregnancy and breastfeeding

• Pregnancy
  • Avoid. Women planning a pregnancy or who have childbearing potential should be switched to an alternative treatment. 
• Breast feeding
  • Not recommended. 

[BNF, 2025; EMC, 2025a]

CGRP inhibitors are recommended as options in NICE guidance for preventing episodic or chronic migraine in adults who have at least 4 migraine days a month, only if at least 3 preventive medicines have not worked or are not tolerated or are unsuitable because of safety concerns.

Available treatments include:

• Atogepant oral tablet — 60 mg daily.

• Rimegepant oral tablet — 75 mg every other day.

CGRP ligand monoclonal antibodies Fremanezumab, Erenumab and Galcanezumab are also available. They are given by subcutaneous injection.

Cautions and contraindications

• Do not prescribe CGRP inhibitors to people with:
  • End-stage renal disease (ESRD) (CLcr <15 mL/min). 
  • Severe hepatic impairment. 
  • Young people (<18 years of age).
  • Medication overuse headache.

• Prescribe CGRP inhibitors with caution in people with:
  • Severe renal impairment (CLcr 15-29 mL/min). In this situation the recommended dosage of Atogepant is 10 mg once daily. No dose adjustment is required for Rimegepant.

Adverse effects

• Common adverse effects include:
  • Nausea.
  • Decreased appetite.
  • Fatigue.

Interactions

Rimegepant and Atogepant have been shown to interact with:

• CYP3A4 Inhibitors such as clarithromycin, itraconazole, ritonavir, diltiazem, erythromycin, fluconazole [Rimegepant and Atogepant].
• CYP Inducers such as phenobarbital, rifampicin, St John's wort, efavirenz, modafinil [Rimegepant].
• P-gp and BCRP only inhibitors such as cyclosporine, verapamil, quinidine [Rimgepant].
• OATP Inhibitors such as rifampicin, atazanavir, ritonavir, tipranavir, ciclosporin, telmisartan [Atogepant].

Pregnancy and breastfeeding

• Pregnancy
  • Avoid CRGP inhibitors during pregnancy.  
• Breast feeding
  • The amounts of CRGP inhibitors found in breast milk are minimal. However, evidence is limited and the developmental and health benefits of breast-feeding should be considered along with the mother's clinical need for the CGRP inhibitor and any potential adverse reactions on the breastfed infant from the medication. If there is doubt seek specialist opinion.

[NICE, 2023a; EMC, 2025b; NICE, 2025e; NICE, 2025b; NICE, 2025c; NICE, 2025d; BNF, 2026; EMC, 2026; Preston, 2026]