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Feature Article

Codeine and headache. ‘Doctor, I just need a script for my headaches’

Shuli Cheng, Elspeth Hutton
OPEN ACCESS

Preventive medications for migraine 

Options to consider for preventing migraine include:

  • amitriptyline (start with 10 mg and build up to 50 mg at night; off-label use)
  • propranolol (start with 10 to 20mg and build up to 40 to 80mg twice daily)
  • topiramate (start with 12.5mg and build up to 50 to 100 mg twice daily)
  • pizotifen (start with 0.5mg and build up to 1.5 mg at night)
  • verapamil, sustained release (start with 90 mg and build up to 240 mg daily; off-label use)
  • candesartan (start with 4 to 8 mg and build up to 24 to 32 mg daily; off-label use). 

Many more migraine preventive medications are available. For patients who fail to respond or tolerate a reasonable dose in eight to 12 weeks, consider changing to another agent or referral to a neurologist for further advice. 

If oral preventive medication fails then therapies such as botulinum toxin type A and erenumab might be considered under the guidance of a neurologist or pain medicine physician. These medications have specific clinical criteria and are not suitable for all patients. 

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Acute treatment of migraine

Acute treatment options for migraine include:

  • soluble aspirin 900 to 1000 mg or ibuprofen 400 to 600mg on a maximum of 15 days per month
  • a triptan, to be used on no more than 10 days per month
  • the addition of metoclopramide or prochlorperazine to acute treatments, which can have additional benefit beyond simply treating nausea 
  • combination therapy with aspirin plus a triptan plus metoclopramide. 

Medication to treat migraine is most effective if taken early in the attack. 

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Tension-type headache

The characteristics of tension-type headache include:

  • mild to moderate headache, lacking associated features
  • lasts 30 minutes to seven days
  • often described as pressure, tightness or ‘band-like’
  • often does not impair the ability to undertake normal daily activities.

Preventive medications for tension-type headache

Preventive medications to consider for frequent tension-type headache include: 

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  • amitriptyline (start with 10mg, build up to 50mg at night; off-label use)
  • mirtazapine (start with 15mg, increase to 30mg as tolerated; off-label use)
  • venlafaxine, modified release (start with 75mg and increase to 150mg as tolerated; off-label use).

Acute treatment of tension-type headache

Acute treatment options for tension-type headache include:

  • soluble aspirin 600 to 900mg
  • ibuprofen 400mg 
  • naproxen 500 to 750mg 
  • paracetamol 1g.

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Dr Cheng is a Neurologist at Alfred Health, Melbourne. Dr Hutton is a Neurologist at Alfred Health, Melbourne; and Research Fellow in the Neurosciences Department, Monash University, Melbourne, Vic.