Naramig

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Naramig is a prescription-only medicine containing naratriptan hydrochloride 2.5 mg, used for the acute treatment of migraine attacks with or without aura.

It is manufactured by GlaxoSmithKline and belongs to the triptan class of medicines, which are selective serotonin (5-HT1B/1D) receptor agonists.

Naratriptan is distinguished from other triptans by its longer half-life, higher oral bioavailability and lower recurrence rate, making it a particularly useful option for patients whose migraines tend to return within 24 hours of initial treatment.

Naramig is classified as POM in the United Kingdom.

Migraine is a common and disabling neurological condition that affects approximately 1 in 7 people worldwide.

In the United Kingdom, an estimated 10 million people experience migraine, and it is the leading cause of disability in people under 50 according to the Global Burden of Disease study.

Effective acute treatment is essential to reduce the impact of migraine on daily life, work productivity and mental health.

Triptans are the gold standard for moderate to severe migraine attacks and are recommended as first-line acute therapy by NICE.

This page provides a comprehensive clinical overview of Naramig, including how it works, dosage guidance, side effects, important safety warnings, and how to obtain a prescription in the UK.

Important safety information about Naramig

• Naramig is a prescription-only medicine for acute migraine attacks. It is not for prevention or for other types of headache.
• Do not take Naramig if you have a history of heart attack, stroke, angina, peripheral vascular disease or uncontrolled high blood pressure.
• Do not take Naramig within 24 hours of using another triptan or ergotamine-containing medicine.
• Overuse of triptans (10 or more days per month) can cause medication-overuse headache.
• Side effects include tingling, warmth, heaviness, fatigue and dizziness.

Understanding migraine

Migraine is a complex neurological disorder characterised by recurrent episodes of moderate to severe headache, typically unilateral and pulsating, often accompanied by nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia).

Approximately one third of people with migraine experience aura, which may include visual disturbances (flashing lights, zigzag lines, blind spots), sensory symptoms (tingling, numbness) or speech difficulties, usually lasting 5 to 60 minutes before the headache begins.

The pathophysiology of migraine involves activation of the trigeminovascular system.

Trigeminal nerve fibres innervating the meningeal blood vessels release pro-inflammatory neuropeptides, particularly calcitonin gene-related peptide (CGRP) and substance P, causing neurogenic inflammation and vasodilation of intracranial arteries.

This process is mediated through serotonin (5-HT) pathways, and triptans work by targeting these pathways to reverse the pathological changes.

How Naramig works: mechanism of action

Naratriptan is a selective agonist of serotonin 5-HT1B and 5-HT1D receptors.

It has no significant activity at other serotonin receptor subtypes or at adrenergic, dopaminergic, histaminergic or muscarinic receptors.

This selectivity accounts for its targeted action in migraine with relatively few systemic side effects.

Activation of 5-HT1B receptors on intracranial blood vessels causes vasoconstriction, reversing the migraine-associated vasodilation.

Activation of 5-HT1D receptors on trigeminal nerve terminals inhibits the release of CGRP and other pro-inflammatory neuropeptides, blocking neurogenic inflammation.

Additionally, naratriptan may act on 5-HT1B/1D receptors in the brainstem trigeminal nucleus caudalis, interrupting central pain transmission.

These three mechanisms work together to relieve the headache, nausea and sensory sensitivity of a migraine attack.

Pharmacokinetics: why naratriptan is different

Naratriptan has a distinctive pharmacokinetic profile that sets it apart from other triptans.

It is absorbed more slowly than sumatriptan or rizatriptan, with peak plasma concentrations reached at 2 to 3 hours compared with approximately 1.5 hours for sumatriptan.

The oral bioavailability is 63 to 74 percent, higher than sumatriptan (approximately 14 percent oral) and rizatriptan (approximately 45 percent).

The elimination half-life is approximately 6 hours, the longest of any triptan (sumatriptan approximately 2 hours, rizatriptan approximately 2 to 3 hours, eletriptan approximately 4 hours).

The clinical implications of this pharmacokinetic profile are threefold.

First, the onset of action is somewhat slower, which means naratriptan may take longer to provide initial relief compared with faster-acting triptans.

Second, the sustained plasma levels result in a lower rate of headache recurrence within 24 hours.

In clinical trials, headache recurrence rates with naratriptan were approximately 17 to 28 percent, compared with 30 to 40 percent for sumatriptan.

Third, the overall side-effect burden tends to be lower, with fewer reports of chest tightness, flushing and "triptan sensations."

Clinical evidence and UK guidance

The efficacy of naratriptan in acute migraine has been established in multiple double-blind, placebo-controlled trials.

In pivotal studies, 2.5 mg naratriptan provided headache relief (reduction from moderate or severe to mild or none) in approximately 60 to 68 percent of patients at 4 hours compared with 33 to 39 percent for placebo.

Pain-free rates at 4 hours were approximately 40 to 45 percent with naratriptan compared with 15 to 20 percent with placebo.

NICE guideline CG150 (Headaches in over 12s: diagnosis and management) recommends offering a triptan for the acute treatment of migraine.

The guideline states that a triptan should be offered to people with migraine whose attacks do not respond adequately to simple analgesia (paracetamol or an NSAID).

No single triptan is recommended over another; instead, NICE advises trying a different triptan if the first one tried is ineffective, as individual response varies.

Naratriptan may be particularly suitable for patients who experience frequent headache recurrence with faster-acting triptans, or who find that other triptans cause troublesome side effects.

The BASH (British Association for the Study of Headache) guidelines support the use of triptans as first-line treatment for moderate to severe migraine and note that combining a triptan with an NSAID (such as naproxen) or paracetamol may improve response rates.

BASH also emphasises the importance of taking triptans early in the headache phase for optimal efficacy.

Naramig compared with other triptans

Seven triptans are available in the UK: sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan and frovatriptan. They share the same mechanism of action but differ in their pharmacokinetic properties, onset, duration and side-effect profiles.

Sumatriptan is the original triptan and the most widely prescribed.

It is available as tablets, nasal spray, injection and (since 2023 in the UK) as a pharmacy medicine for adults without prescription.

Sumatriptan has a faster onset but a shorter half-life and higher recurrence rate than naratriptan.

Rizatriptan (Maxalt) has a rapid onset (1 to 1.5 hours) and is available as an orodispersible wafer, which is useful when nausea is prominent.

Eletriptan (Relpax) has the highest efficacy in head-to-head trials but requires a prescription and may cause more side effects.

Zolmitriptan is available as tablets, orodispersible tablets and nasal spray. Frovatriptan, like naratriptan, has a long half-life (approximately 26 hours) and low recurrence rate but slow onset.

Naratriptan and frovatriptan are sometimes described as the "gentle triptans" because of their lower peak plasma concentrations and reduced side-effect burden.

Naratriptan is often tried in patients who have found sumatriptan effective but who experience troublesome recurrence or side effects.

It is also used for short-term menstrual migraine prophylaxis, taken twice daily during the perimenstrual window, although this is an off-label use.

Dosage and administration

The recommended dose of Naramig is one 2.5 mg tablet, taken as soon as possible after the onset of migraine headache.

If the headache resolves and then returns, a second tablet may be taken after at least 4 hours.

The maximum dose is 5 mg (two tablets) in 24 hours.

If the first dose has no effect at all on the attack, do not take a second tablet for that episode.

Take the tablet whole with water. It can be taken with or without food.

Naramig should be taken during the headache phase, not during the aura before the pain develops. Early treatment during the headache phase generally produces the best results.

In renal or hepatic impairment (mild to moderate), the maximum dose is 2.5 mg in 24 hours. Naramig is contraindicated in severe renal or hepatic impairment.

It is licensed for adults aged 18 and over and is not recommended for patients over 65 or for children.

Side effects of Naramig

Common side effects

Tingling, warmth, heaviness and pressure sensations (sometimes called "triptan sensations") are the most characteristic side effects, affecting approximately 1 in 20 users.

These may occur in the chest, throat, neck, limbs or other areas and usually resolve within 30 minutes. Fatigue, drowsiness, dizziness, nausea and flushing are also common.

Chest symptoms

Tightness, pressure or pain in the chest and throat have been reported. In most cases, these are non-cardiac in origin (oesophageal spasm, skeletal muscle effects).

However, because triptans can cause coronary vasoconstriction, any chest pain following triptan use should be evaluated, especially in patients with cardiovascular risk factors.

If you experience severe or persistent chest pain, call 999.

Medication-overuse headache

Using triptans on 10 or more days per month for 3 or more consecutive months can lead to medication-overuse headache.

This is a chronic daily headache that paradoxically worsens with continued use of acute treatments. If your migraine frequency increases, consult your prescriber about preventive therapy.

Rare but serious side effects

Serotonin syndrome (when combined with serotonergic medicines), allergic reactions including anaphylaxis, and cardiovascular events (coronary artery vasospasm, myocardial ischaemia) are rare.

Seek immediate medical help if you experience confusion, rapid heartbeat, muscle rigidity, high temperature, severe chest pain, or swelling of the face, lips or throat.

When to seek urgent advice

Call 999 if you experience severe chest pain, signs of a heart attack or stroke, difficulty breathing, or signs of a severe allergic reaction.

Contact NHS 111 for persistent or worrying symptoms. Report adverse reactions to the MHRA at yellowcard.mhra.gov.uk .

Warnings and precautions

Cardiovascular contraindications

Naramig must not be used in patients with ischaemic heart disease, previous myocardial infarction, coronary vasospasm (Prinzmetal's angina), peripheral vascular disease, previous stroke or TIA, or uncontrolled hypertension.

A cardiovascular assessment is recommended before first use in patients with multiple risk factors.

Concurrent triptan or ergotamine use

Do not take Naramig within 24 hours of another triptan or an ergotamine-containing medicine. Concomitant use increases the risk of prolonged vasospasm.

Serotonergic medicines

Use caution when taking Naramig with SSRIs (fluoxetine, sertraline, citalopram), SNRIs (venlafaxine, duloxetine) or MAO inhibitors. Naratriptan is contraindicated with MAO-A inhibitors and must not be taken within 2 weeks of stopping one.

Renal and hepatic impairment

In mild to moderate impairment, the maximum dose is 2.5 mg in 24 hours. Naramig is contraindicated in severe renal or hepatic impairment.

Overuse

Limit use to fewer than 10 days per month to avoid medication-overuse headache.

Pregnancy and breastfeeding

Use during pregnancy only if clearly needed. Avoid breastfeeding for 24 hours after a dose as a precaution. Paracetamol is the preferred analgesic in pregnancy. Discuss migraine management with your midwife or prescriber.

How to get Naramig in the UK

Naramig is a prescription-only medicine available from your GP, headache specialist, or an authorised online prescriber registered with the GPhC. It is available on the NHS.

The standard prescription charge of 9.90 pounds per item applies in England; prescriptions are free in Scotland, Wales and Northern Ireland.

Your pharmacy may dispense generic naratriptan rather than branded Naramig, as both contain the same active ingredient.

Lifestyle advice for migraine management

Acute medication is most effective as part of a broader migraine management strategy.

Keep a migraine diary to identify triggers, which may include stress, irregular sleep, dehydration, certain foods (aged cheese, alcohol, chocolate), hormonal changes, bright or flickering lights, and strong smells.

Maintain regular sleep patterns, eat regular meals, stay well hydrated, and take regular exercise.

If your migraines are frequent (4 or more per month), ask your prescriber about preventive treatment options, which include propranolol, topiramate, amitriptyline, candesartan and CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab).

The National Migraine Centre and Migraine Trust provide further support and information for UK patients.

Sources

• Naramig 2.5 mg Tablets, Summary of Product Characteristics (EMC)
• Naratriptan, British National Formulary (BNF)
• NICE CG150: Headaches in over 12s
• Migraine, NHS
• MHRA Yellow Card Scheme