netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 4: Central nervous system - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

In this section "SPECIALISTS" refer to medical prescribers specialising in Mental Health unless otherwise stated. At Guy's and St Thomas' and Lewisham Hospitals this would refer to SLAM employed consultants

 Details...
04.07.04  Expand sub section  Antimigraine drugs
04.07.04.01  Expand sub section  Treatment of the acute migraine attack
Ibuprofen tabs
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Formulary  
   
Paracetamol tabs, soluble tabs
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Formulary  
   
Chlorpromazine intramuscular injection (migraine symptoms on inpatient withdrawal regimens in medication overuse headache)
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Formulary
Red

Approved off-label indication:

Migraine symptoms on withdrawal regimens in medication overuse headache

Usual dose = 12.5 mg to 25 mg up to three times a day as required

As part of an inpatient withdrawal regimen only

 
   
Chlorpromazine tabs (migraine symptoms on withdrawal regimens in medication overuse headache)
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Formulary
Red

Approved off-label indication:

Migraine symptoms on withdrawal regimens in medication overuse headache

Usual dose = 10 mg to 25 mg up to three times a day as required

 
   
Clonidine tabs (opioid withdrawal symptoms - off-label)
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Formulary
Red

Approved off-label indication:

Opioid withdrawal symtpoms in medication overuse headache and chronic pain

Usual dose = 50 micrograms - 100 micrograms three times a day as required

 
   
Lidocaine infusion
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Restricted Drug Restricted
Red

Joint Formulary Committee approved off-label use (specialist headache clinic use only):

  • Short-lasting Unilateral Neuralgiform Headache attacks with conjunctival injection and Tearing (SUNCT)
  • Short-lasting Unilateral Neuralgiform Headache attacks with Cranial Autonomic Symptoms (SUNA)

See dosing protocol from KCH for further information

 
   
Aspirin injection (severe headache)
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Unlicensed Drug Unlicensed
Red

SPECIALIST USE ONLY

Inpatient management of severe withdrawal headache

Dose = 1g once to three times daily for up to 4 days

 
   
Indometacin injection (diagnosis of indometacin sensitive headaches)
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Unlicensed Drug Unlicensed
Red

SPECIALIST USE ONLY

For the diagnosis of indometacin sensitive headaches (paroxysmal hemicranias)

Dose = 100-200mg intramuscular test dose

 
   
04.07.04.01  Expand sub section  5HT1 agonists
Rizatriptan wafers
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Formulary  
   
Sumatriptan tabs, injection
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Formulary  
   
04.07.04.01  Expand sub section  Ergot alkaloids
Dihydroergotamine injection (migraine)
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Unlicensed Drug Unlicensed
Red

SPECIALIST USE ONLY

Inpatient treatment of medical refractory disabling migraine and cluster headaches.

See dosing protocol from KCH for further information

 
   
04.07.04.01  Expand sub section  Anti-emetics to top
Metoclopramide tabs
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Formulary Maximum daily dose of 30mg for a maximum of 5 days. See MHRA davice. 
Link  MHRA advice August 2013: Metoclopramide: risk of neurological adverse effects
   
Prochlorperazine suppositories
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Formulary  
   
04.07.04.02  Expand sub section  Prophylaxis of migraine
Amitriptyline tabs (migraine prophylaxis - off-label)
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Formulary

Use for migraine prophylaxis is off-label

Dose = 10mg at night increasing to 50-75mg at night as per response

 
   
Botulinum Toxin Type A (Botox - migraine)
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Restricted Drug Restricted
Red
High Cost Medicine
Approved for use as per resctritions in the NICE guidance for the use of botulinum toxin in chronic migraine 
Link  NICE TA260: Botox for migraine prophylaxis
   
Lidocaine injection 2% (chronic headache - off-label)
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Restricted Drug Restricted
Red

Approved off-label indication (specialist headache clinic use only):

Greater occipital nerve block for treatment of chronic headache.

  • Restricted to use where oral and other conventional treatments are insufficient or not tolerated.
  • Dose = 3ml (60mg)
 
   
Methylprednisolone acetate 80mg (Depo-Medrone - chronic headache)
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Restricted Drug Restricted
Red

Approved off-label indication (specialist headache clinic use only):

Greater occipital nerve block for treatment of chronic headache.

  • Restricted to use where oral and other conventional treatments are insufficient or not tolerated.
  • Given in conjunction with with 3ml of lidocaine 2% (i.e. 60mg of lidocaine plus 80mg methylprednisolone acetate)
 
   
Pizotifen tabs, elixir
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Formulary  
   
Propranolol tabs (migraine prophylaxis)
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Formulary  
   
Sodium valproate tabs (migraine prophylaxis - off-label)
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Restricted Drug Restricted
Amber 2

USE ON SPECIALIST ADVICE ONLY

Use in migraine prophylaxis is off-label

Valproate must no longer be used in any girls or women able to have children unless she agrees to comply with a pregnancy prevention programme.

All women and girls who are prescribed valproate should contact their GP and arrange to have their treatment reviewed.

Communication materials have been provided by the manufacturers to discuss the risk of abnormal pregnancy outcomes with women and girls of childbearing potential. See links below.

 
Link  Valproate Annual Risk Acknowledgement Form
Link  Valproate- Patient Guide-Educational material- Pregnancy prevention programme
Link  Valproate- Healthcare professionals (HCPs) Educational material Pregnancy prevention programme
Link  MHRA Mar 2018: Valproate use by women and girls
Link  MHRA Apr 2017: Valproate and developmental disorders: new alert asking for patient review and further consideration of risk minimisation measures
Link  MHRA Feb 2016: Valproate and risk of abnormal pregnancy outcomes: new communication materials
   
Topiramate tabs, sprinkles (migraine prophylaxis)
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Formulary
Amber 2
 
   
Methysergide tabs
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Formulary REQUIRES HOSPITAL SUPERVISION 
   
04.07.04.03  Expand sub section  Cluster headache
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Red

Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

Amber 1

Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

Amber 2

Specialist initiation followed by maintenance prescribing in primary care  

Amber 3

Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

Green

Specialist and non-specialist initiation  

Grey

Not recommended for prescribing  

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