This promotional material is intended for UK Healthcare Professionals only. BOTOX® (botulinum toxin type A) Prescribing Information and adverse event reporting information can be found below.
Treatment options
Treatment options for the management of migraine may include:5-9
• Analgesics, especially NSAIDS
• Anti-emetics
• Specific anti-migraine drugs: serotonin 5-HT1 receptor agonists or triptans
• Rimegepant
• Natural remedies (including riboflavin)
• Pharmacological treatments such as anti-convulsants or beta‑blockers
• BOTOX® (botulinum toxin type A)5
• CGRP receptor antagonists (AQUIPTA®▼ (atogepant)* and rimegepant)6,7
• Monoclonal antibodies (eptinezumab, fremanezumab, erenumab and galcanezumab)
(according to NICE Headaches in over 12s: diagnosis and management (CG150), 2012, updated 2025)10
- Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12-17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12 to 17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s.
- When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting
- For people in whom oral preparations (or nasal preparations in young people aged 12-17 years) for the acute treatment of migraine are ineffective or not tolerated:
- offer a non-oral preparation of metoclopramide or prochlorperazine and
- if non-oral metoclopramide or prochlorperazine is used, consider adding a non-oral NSAID or triptan if they have not been tried.
- Note the special warnings and precautions for use in the SmPC for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
- In June 2025, only a buccal preparation of prochlorperazine was licensed for this indication (other preparations of prochlorperazine and metoclopramide were licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people.
- Rimegepant (an oral CGRP inhibitor placed on or under the tongue) is recommended as an option in NICE technology appraisal guidance for the acute treatment of migraine with or without aura in adults, 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.
- Do not offer ergots or opioids for the acute treatment of migraine
(according to NICE Headaches in over 12s: diagnosis and management (CG150), 2012, updated 2025)10
- Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12-17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12 to 17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s.
- When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting
- For people in whom oral preparations (or nasal preparations in young people aged 12-17 years) for the acute treatment of migraine are ineffective or not tolerated:
- offer a non-oral preparation of metoclopramide or prochlorperazine and
- if non-oral metoclopramide or prochlorperazine is used, consider adding a non-oral NSAID or triptan if they have not been tried.
- Note the special warnings and precautions for use in the SmPC for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
- In June 2025, only a buccal preparation of prochlorperazine was licensed for this indication (other preparations of prochlorperazine and metoclopramide were licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people.
- Rimegepant (an oral CGRP inhibitor placed on or under the tongue) is recommended as an option in NICE technology appraisal guidance for the acute treatment of migraine with or without aura in adults, 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.
- Do not offer ergots or opioids for the acute treatment of migraine
(according to NICE Headaches in over 12s: diagnosis and management (CG150), 2012, updated 2025)10
- Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12-17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12 to 17 years consider a nasal triptan in preference to an oral triptan.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s. Because of the association with Reye's syndrome, preparations containing aspirin should not be offered to under 16s.
- When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.
- In June 2025, this was an off-label use of triptans (except nasal sumatriptan) in under 18s.
- Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting
- For people in whom oral preparations (or nasal preparations in young people aged 12-17 years) for the acute treatment of migraine are ineffective or not tolerated:
- offer a non-oral preparation of metoclopramide or prochlorperazine and
- if non-oral metoclopramide or prochlorperazine is used, consider adding a non-oral NSAID or triptan if they have not been tried.
- Note the special warnings and precautions for use in the SmPC for metoclopramide and prochlorperazine, and discuss the benefits and risks with the person (or their parents or carers, as appropriate).
- In June 2025, only a buccal preparation of prochlorperazine was licensed for this indication (other preparations of prochlorperazine and metoclopramide were licensed for the relief of nausea and vomiting); nasal sumatriptan was the only triptan licensed for this indication in under 18s. This was an off-label use of metoclopramide in children and young people.
- Rimegepant (an oral CGRP inhibitor placed on or under the tongue) is recommended as an option in NICE technology appraisal guidance for the acute treatment of migraine with or without aura in adults, 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.
- Do not offer ergots or opioids for the acute treatment of migraine
BOTOX® is recommended as an option for the prophylaxis of headaches in adults with chronic migraine5
NICE recommendation9
1.1 Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine), only if:
- at least 3 preventive medicines have not worked, or are not tolerated or are unsuitable because of safety concerns, and
- the condition is appropriately managed for medication overuse.
1.2 Treatment with botulinum toxin type A that is recommended according to section 1.1 should be stopped in people whose condition:
- is not adequately responding to treatment (defined as less than a 30% reduction in headache days per month after 2 treatment cycles) or
- has changed to episodic migraine (defined as fewer than 15 headache days per month) for 3 consecutive months.
1.3 People currently receiving botulinum toxin type A that is not recommended according to sections 1.1 and 1.2 should have the option to continue treatment until they and their clinician consider it appropriate to stop.
SMC recommendation:11
Botulinum toxin A (BOTOX®) is accepted for restricted use within NHS Scotland.
Indication under review: Prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine).
SMC restriction: use in adults with chronic migraine whose condition has failed to respond to ≥3 prior oral prophylactic treatments, where medication overuse has been appropriately managed.
No stopping rules for BOTOX® are outlined by the SMC.
Chronic migraine is a complex neurological disease requiring appropriate effective management - including treatment or referrals to improve patient outcomes2,12,13
CGRP: calcitonin gene-related peptide; CM: chronic migraine; NICE: National Institute for Health and Care Excellence; NSAID: non-steroidal anti-inflammatory drug; SMC: Scottish Medicine Consortium
*AQUIPTA® is indicated for the prophylaxis of migraine in adults who have at least 4 migraine days per month.6
© NICE [2012] Headaches in over 12s: diagnosis and management. Available from nice.org.uk. All rights reserved. Subject to Notice of rights
© NICE [2012] Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. Available from nice.org.uk. All rights reserved. Subject to Notice of rights.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Please refer to the BOTOX® Summary of Product Characteristics for further information on adverse events, contraindications and special warnings and precautions for use. The BOTOX® Summary of Product Characteristics can be found here
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Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/
Adverse events should also be reported to AbbVie on GBPV@abbvie.com
Date of preparation: July 2025. UK-BCM-250054.
