Migraine treatment: Moderate to severe (Formulary: CNS)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Guidelines

Reserve triptans for patients resistant to simple analgesics and antiemetic therapy; if the headache always progresses to a moderate to severe attack despite patients taking acute therapy when symptoms are still mild, then consider triptans.

Use during the established headache phase and not during the aura phase of an attack.

Continue triptan treatment for 3 months and only discontinue at that point if ineffective. If one triptan is ineffective then consider trial of another.

Advise patients that triptans should be taken on no more than 2 days per week due to the risk of developing medication overuse headache.

SUMATRIPTAN - (First line)

Therapy notes

Patients unresponsive to initial dose should NOT take a second dose for the same attack.

Formulation and dosage details

Formulation:

  • Sumatriptan tablets 50mgOTC, 100mg

Formulation and dosage details

Formulation:

  • Sumatriptan solution for injection 6mg/0.5mL

Formulation and dosage details

Formulation:

  • Sumatriptan nasal spray 10mg/0.1mL unit-dose spray, 20mg/0.1mL unit-dose spray

RIZATRIPTAN

Therapy notes

ALTERNATIVE to sumatriptan where a more potent and rapidly acting treatment is required. 

Note: The metabolism of rizatriptan is affected by propranolol. Avoid rizatriptan completely within 2 hours of taking propranolol. At other times, patients taking propranolol should take only 5mg rizatriptan.

Formulation and dosage details

Formulation:

  • Rizatriptan tablets 5mg, 10mg

Formulation and dosage details

Formulation:

  • Rizatriptan orodispersible tablets 10mg

ZOLMITRIPTAN

Therapy notes

Formulation and dosage details

Formulation:

  • Zolmitriptan tablets 2.5mg

Formulation and dosage details

Formulation:

  • Zolmitriptan orodispersible tablets 2.5mg, 5mg

Formulation and dosage details

Formulation:

  • Zolmitriptan nasal spray 5mg/0.1mL unit-dose spray

RIMEGEPANT

Therapy notes

Formulation and dosage details

Formulation:

  • Rimegepant oral lyophilisate 75mg 

Indication: 

  • As per SMC 2521 (Vydura®): For the acute treatment of migraine with or without aura in adults.
    SMC restriction: for patients who have had inadequate symptom relief after trials of at least two triptans or in whom triptans are contraindicated or not tolerated; and have inadequate pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.

Notes:

Editorial Information

Last reviewed: 30/04/2026

Version: 2

Document Id: F070