NICE vs SIGN: Management of Migraine (2025) - A Clinical Comparison
This guideline provides a detailed, factual comparison of the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) approaches to the management of migraine. While there is significant alignment, key differences in treatment sequencing and special situations are crucial for clinicians to understand. This comparison is based on the latest NICE guideline (NG217, September 2021) and the SIGN guideline (SIGN 155, Updated December 2018, with key recommendations still current for 2025).
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Diagnosis and Assessment
Both NICE and SIGN align closely on the fundamental principles of diagnosis, which is primarily clinical based on the International Classification of Headache Disorders (ICHD-3) criteria.
NICE (NG217)
- Focus: Emphasises a positive diagnosis of migraine, distinguishing it from other headache types, and assessing the impact on quality of life.
- Assessment: Recommends using a headache diary for at least 8 weeks to aid diagnosis and identify potential triggers. Stresses the importance of identifying medication-overuse headache.
- Red Flags: Provides clear guidance on identifying "red flag" symptoms that warrant urgent investigation (e.g., thunderclap headache, new neurological deficit).
SIGN (155)
- Focus: Similarly based on ICHD-3 criteria. Provides a very detailed diagnostic checklist to ensure all criteria are met.
- Assessment: Also advocates for the use of headache diaries. Includes a stronger emphasis on the psychosocial impact and comorbidity, particularly with anxiety and depression.
Key Difference: There are no major differences in diagnostic criteria. SIGN offers a more structured checklist, while NICE places greater emphasis on the functional impact from the outset.
Acute Treatment
Both guidelines recommend a stratified approach, treating attacks early with the most effective medication tolerated by the patient. The core recommendations for simple analgesia are similar, but key divergences appear in the subsequent steps.
NICE (NG217)
- First-line: Offers an oral triptan AND a non-steroidal anti-inflammatory drug (NSAID) OR an oral triptan AND paracetamol.
- Alternative: If the above is ineffective or not tolerated, consider a different triptan or a non-oral triptan/NSAID (e.g., nasal/spray/suppository).
- Anti-emetics: Recommends an anti-emetic (e.g., metoclopramide or prochlorperazine) even in the absence of nausea, for its prokinetic effect to aid absorption of oral medication.
SIGN (155)
- First-line: A step-wise approach. Start with aspirin (900mg) OR an NSAID. Paracetamol is considered less effective.
- Second-line: If first-line is insufficient, add or switch to a triptan.
- Anti-emetics: Recommends adding a parenteral anti-emetic (e.g., metoclopramide) for associated nausea and vomiting.
Key Difference & Practical Takeaway: This is the most significant divergence. NICE recommends a combination of a triptan and an NSAID/paracetamol as a first-line option, advocating for a more aggressive initial attack strategy. SIGN adopts a more traditional step-care approach, reserving triptans for when NSAIDs/aspirin fail. The NICE approach may lead to faster and more complete pain relief for suitable patients.
Prophylactic (Preventive) Treatment
Indications for prophylaxis are similar in both guidelines: frequent attacks (typically ≥4 headache days per month), significant disability despite acute treatment, or unacceptable adverse effects from acute medications.
NICE (NG217)
- First-line: Topiramate or Propranolol based on patient comorbidities, contraindications, and preference.
- Newer Therapies: Includes recommendations for anti-CGRP monoclonal antibodies (e.g., erenumab, fremanezumab) for patients who have failed three preventive treatments.
- Other options: Amitriptyline is recommended as a option, considering its side effect profile.
SIGN (155)
- First-line: Propranolol or Amitriptyline. Topiramate is also a first-line option.
- Newer Therapies: The 2018 SIGN guideline predates NICE approval of anti-CGRP therapies and does not include them. Scottish clinicians must refer to local NHS Scotland formularies and the Scottish Medicines Consortium (SMC) for current availability.
- Other options: Candesartan and sodium valproate are mentioned as alternatives.
Key Difference & Practical Takeaway: The main difference is the formal inclusion of anti-CGRP monoclonal antibodies in the NICE guideline, providing a clear pathway for severe, treatment-refractory migraine. SIGN's list of first-line preventives is broader, with a strong emphasis on propranolol and amitriptyline.
Special Situations
Menstrual Migraine
- NICE: Suggests consider using a triptan or NSAID for short-term prophylaxis (mini-prophylaxis) during the peri-menstrual period.
- SIGN: Provides more detailed recommendations, suggesting mefenamic acid or a triptan (e.g., frovatriptan or zolmitriptan) for mini-prophylaxis.
Chronic Migraine (& Medication-Overuse Headache)
- Both guidelines stress the importance of diagnosis and managing medication-overuse headache, which often underpins chronic migraine (>15 headache days/month).
- NICE: Explicitly recommends Botox (onabotulinumtoxinA) for chronic migraine as per its NICE TA260 guidance, in addition to anti-CGRP therapies.
- SIGN: Discusses Botox but defers to specific SMC advice. The core management is withdrawal of the overused medication and initiation of a prophylactic agent.
Pregnancy and Breastfeeding
- Both: Recommend paracetamol as first-line for acute treatment. The use of triptans is more cautiously discussed, with SIGN being slightly more permissive in its wording for sumatriptan after the first trimester, while NICE advises to "avoid".
- For prophylaxis, both advise non-pharmacological measures first. If essential, propranolol or amitriptyline may be considered after specialist review.
Practical Clinical Flow: A Synthesis
A pragmatic UK approach, synthesising both guidelines, might look like this:
- Diagnosis: Confirm using ICHD-3 criteria. Use a headache diary. Assess impact and screen for medication overuse.
- Acute Treatment:
- For rapid relief: Consider the NICE approach of a triptan + NSAID from the outset.
- For a cautious approach or mild attacks: Start with SIGN's step-care (high-dose aspirin/NSAID first, then add a triptan if needed).
- Always consider: Adding an anti-emetic (e.g., 10mg metoclopramide) to aid absorption.
- Prophylaxis: Initiate if attacks are frequent or disabling.
- First-line: Topiramate, Propranolol, or Amitriptyline (choose based on comorbidity and profile).
- If 3+ preventives fail and criteria are met (England/Wales): Refer for consideration of anti-CGRP therapy or Botox (for chronic migraine).
- Review: Assess efficacy and adverse effects at 4-8 weeks. Encourage lifestyle management and trigger avoidance where relevant.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow in Scotland/Northern Ireland/England/Wales?
Clinicians should primarily follow the guideline relevant to their national health service (SIGN for Scotland, NICE for England, Wales, and Northern Ireland). However, understanding the other guideline is valuable, especially where NICE includes newer therapies. Local NHS board or trust formularies will ultimately dictate drug availability.
2. What is the single biggest practical difference in daily practice?
The approach to acute treatment. NICE's endorsement of a triptan + NSAID as a first-line combination is a more aggressive and potentially more effective initial strategy compared to SIGN's step-wise care. This NICE approach can be adopted across the UK if clinically appropriate.
3. Are anti-CGRP monoclonal antibodies available in Scotland?
Yes, but their adoption is guided by the Scottish Medicines Consortium (SMC) rather than the older SIGN guideline. The SMC has approved several anti-CGRP therapies (e.g., erenumab, fremanezumab) for use within NHS Scotland, often with similar but not identical criteria to NICE.
4. How should I manage medication-overuse headache?
Both guidelines are aligned: education, withdrawal of the overused medication (abruptly for triptans/opioids, gradually for analgesics), initiation of a prophylactic agent, and close support. Withdrawal can be facilitated by a short course of steroids or NSAIDs.
5. Is there a role for complementary therapies?
Both guidelines are cautious. NICE suggests considering a course of up to 10 sessions of acupuncture. SIGN states the evidence is insufficient to support routine recommendation. Neither supports herbal remedies like butterbur due to safety concerns.
Source Links
- NICE Guideline NG217 (Migraine): NICE NG217
- SIGN Guideline 155 (Pharmacological management of migraine): SIGN 155 (PDF)
- NICE Technology Appraisal TA260 (Botox for chronic migraine): NICE TA260
- Scottish Medicines Consortium (SMC): Scottish Medicines Consortium