"Just take paracetamol and lie down in a dark room."— what you've probably been told
Migraine
NICE CG150 sets the diagnostic pathway for migraine and the order in which preventive treatments should be tried (propranolol, topiramate, amitriptyline, candesartan). Once a patient has failed at least four preventives, separate NICE Technology Appraisals cover CGRP monoclonal antibody injections (TA682 erenumab, TA659 galcanezumab, TA764 fremanezumab, TA871 eptinezumab) and TA260 covers Botox for chronic migraine.
The wait: Most patients fail 2–3 preventives before anyone mentions CGRP injections.
GPs often stop at one or two preventives and never document the failure trail that unlocks CGRP injections or Botox. Medication-overuse headache from daily triptans or codeine is also routinely missed, and patients are rarely told that CGRP injections are NHS-funded under specific NICE TAs once the preventive ladder is exhausted.
- A CG150-aligned diagnosis (migraine with/without aura, chronic migraine, medication-overuse headache)
- A documented preventive trial history, with dose and duration for each preventive offered
- Neurology referral where ≥4 preventives have been tried without benefit, citing the CGRP TA criteria (TA682, TA659, TA764, TA871)
- Consideration of Botox for chronic migraine under TA260 where criteria are met
- A medication-overuse headache review where acute treatments are used on ≥10–15 days per month
Can my GP prescribe CGRP injections?
No — CGRP monoclonal antibodies are specialist-initiated under the relevant NICE TAs. The letter asks the GP to refer to neurology once the documented preventive trail meets the TA criteria.
What counts as a failed preventive?
Generally an adequate dose for at least 6–8 weeks without meaningful benefit, or stopped due to intolerable side effects. The letter asks for that history to be written down so the neurology referral isn't bounced.
What's usually said in the room
"Just take paracetamol and lie down in a dark room."
What the guideline actually says
GPs often stop at one or two preventives and never document the failure trail that unlocks CGRP injections or Botox. Medication-overuse headache from daily triptans or codeine is also routinely missed, and patients are rarely told that CGRP injections are NHS-funded under specific NICE TAs once the preventive ladder is exhausted.
Source: Headaches in over 12s: diagnosis and management (CG150)
Outcomes from people with Migraine
One short email each Sunday — anonymised stories from people who got their GP to take them seriously.