Overall proposal

We propose amending recommendation 1.3.17 about the use of propranolol and topiramate for the prevention of migraine to make it a 'consider' recommendation alongside amitriptyline to better reflect the balance between the benefits and harms associated with the use of these medicines.

Current Recommendation	Proposed change
1.3.17 For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion: the potential benefit in reducing migraine recurrence and severity the risk of fetal malformations with topiramate the risk of reduced effectiveness of hormonal contraceptives with topiramate the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method). Follow the MHRA safety advice on antiepileptic drugs in pregnancy. [2015, amended 2021] In November 2015, this was an off-label use of topiramate in children and young people. See NICE's information on prescribing medicines. People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.	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.
1.3.18 Consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. In November 2015, this was an off-label use of amitriptyline. See NICE's information on prescribing medicines. [2015] 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.

Current Recommendation

Proposed change

1.3.17

For the prophylaxis of migraine, offer topiramate or propranolol after a full discussion of the benefits and risks of each option. Include in the discussion:

the potential benefit in reducing migraine recurrence and severity

the risk of fetal malformations with topiramate

the risk of reduced effectiveness of hormonal contraceptives with topiramate

the importance of effective contraception for women and girls of childbearing potential who are taking topiramate (for example, by using medroxyprogesterone acetate depot injection, an intrauterine method or combined hormonal contraception with a barrier method).

Follow the MHRA safety advice on antiepileptic drugs in pregnancy. [2015, amended 2021]

In November 2015, this was an off-label use of topiramate in children and young people. See NICE's information on prescribing medicines.

People with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, in line with the Healthcare Safety Investigation Branch's report on the under-recognised risk of harm from propranolol.

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.

1.3.18

Consider amitriptyline for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events.

In November 2015, this was an off-label use of amitriptyline. See NICE's information on prescribing medicines. [2015]

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.

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Question on Consultation

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)

Overall proposal