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Is it migraine? A summary of the Pharmacy First pathway for adults aged 18 and over, from the ID Migraine screen to treatment options, referral criteria and self-care advice.
5 or more attacks lasting 4–72 hours if untreated or treatment fails1
●
2 or more of: one-sided, pulsating, moderate or severe, worse with activity1
●
1 or more of: nausea or vomiting; light and sound sensitivity together1
Referral
Phone 999 if any of the following are present
●
Rapid-onset severe headache, reaching its worst within 5 minutes2,4
●
Confusion, weakness of an arm or leg, face drooping or slurred speech2,4
●
High temperature, especially with confusion, being unable to put the chin to the chest, or a rash that does not fade when pressed2,4
Hospital emergency department
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Head knock in the last 3 months while taking an anticoagulant, antiplatelet (except aspirin alone) or having a bleeding or clotting disorder2,4
●
First episode of atypical or prolonged aura: not fully reversible or lasting over 60 minutes, motor weakness, double vision, symptoms in one eye only, poor balance or reduced consciousness1,2
●
Severe, uncontrolled migraine lasting more than 72 hours (status migrainosus)3
●
Papilloedema; new focal neurological deficit, personality change, cognitive impairment or altered consciousness2,4
Headache triggered by cough, Valsalva or sneeze, or worse on standing or lying down2,4
●
Head knock in the last 3 months (without the anticoagulant or bleeding risk above); over 50 with a completely new type of headache; immunocompromised or cancer; or headaches worsening week on week for a month or more and not responding to treatment2,4
●
Under 18, 8 or more headache days in the last month, or a major change in pattern1,2
●
Other episodes of atypical or prolonged aura, or uncertain diagnosis1,2,3
4 or more migraine days in the last month: consider preventive treatment; acute treatment may continue1,2
●
ID Migraine screen or ICHD-3 criteria not met: migraine less likely. Infrequent tension-type headache: self-care advice; other headache: refer1
●
Migraine with aura and combined hormonal contraception: non-urgent contraception review (GP, sexual health service or NHS Pharmacy Contraception Service). Do not stop the contraception without an effective alternative1,2
Treatment options
Treatment options
●
NSAID: aspirin 900 mg, ibuprofen 400–600 mg or naproxen 250–500 mg orally. Take with or after food, at the lowest effective dose2
●
Paracetamol 1,000 mg orally if NSAIDs are contraindicated or not tolerated. It is rarely effective alone2
●
Triptan, following the local formulary: for example sumatriptan 50–100 mg orally. Consider zolmitriptan nasal spray for severe vomiting or if rapid onset is needed2
●
If initial triptan ineffective (no significant response at 2 hours): try an alternative triptan2
●
Antiemetic: prochlorperazine 3 mg buccal, metoclopramide 10 mg or domperidone 10 mg orally. The latter two may be used without nausea, short term only, in line with MHRA advice2
●
Paracetamol, an NSAID and a triptan may be taken individually or in combination as an individualised approach2
Cardiovascular disease (including ischaemic heart disease, previous MI, Prinzmetal's angina, arrhythmias, peripheral vascular disease, mild uncontrolled or controlled moderate or severe hypertension)2
●
Previous TIA or stroke; use with another triptan, an MAOI or ergotamine2
●
Aged 65 and over: no upper age limit, but a triptan is off-label2
Self-care and advice
Self-care
●
Take treatment early, at headache onset, not during aura1
●
Painkillers on no more than 2 days a week (including triptans and codeine); avoid opioids. If taken on 2 or more days a week, advise on reducing use, then return to the pathway. Overuse can cause medication overuse headache1,2,3
Avoid known triggers; stress management, good sleep, hydration, regular meals and exercise can help. Migraine cannot be cured but can usually be managed3
●
Provide patient information: The Migraine Trust self-management advice1,5
Safety-netting advice for patient
●
Seek urgent help if the headache changes or new symptoms develop1
Follow up
Ask the patient to return if
●
Any acute treatment is ineffective on 3 treated attacks1
●
CKS advises review within 2–8 weeks of starting treatment (attack frequency, effectiveness, adverse effects, overuse)3
Returning patient: one further consultation only
●
Reassess and agree an alternative acute plan only if ALL apply: 0–7 headache days and fewer than 4 migraine days in the last month; appropriate dose, timing and formulation; painkiller use within limits; no red flags or signposting criteria1,2
●
If the alternative plan is ineffective: refer to general practice1,2
NICE Clinical Knowledge Summaries. Migraine. Scenario: Migraine in adults (from age 18 years). Last revised April 2026. Management: information and self-care advice; acute treatment; follow up; referral.
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