Amendment of recommendation 1.3.17 about the use of propranolol, topiramate and amitriptyline in Headaches in over 12s: diagnosis and management (NICE guideline CG150)
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Amendment proposal
We propose changing recommendation 1.3.17 in NICE guideline CG150 - 'Headaches in over 12s: diagnosis and management' to a 'consider' recommendation for propranolol, topiramate or amitriptyline. Currently the guideline recommends to 'offer topiramate or propranolol after a full discussion of the benefits and risks of each option' for the prophylaxis of migraine, and to 'consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events'. We propose changing the recommendation for topiramate or propranolol from 'offer' to 'consider' to better reflect the benefits and harms associated with all 3 medicines.
The following wording is proposed:
For migraine prevention, consider propranolol, topiramate or amitriptyline after a full discussion of the benefits, risks and suitability of each option. Take into account:
The potential benefit in reducing migraine recurrence and severity
People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol to minimise the risk of harm from toxicity and rapid deterioration in overdose in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.
Topiramate should not be used in pregnancy for prophylaxis of migraine, or in women able to have children unless the conditions of the Pregnancy Prevention Programme are fulfilled. See the MHRA advice on the use of topiramate.
For guidance on safe prescribing of antidepressants (such as amitriptyline) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.
In April 2025, this was an off-label use of topiramate and amitriptyline in children and young people. See NICE's information on prescribing medicines.
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