‘Safety First: Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness’ recommends that patients at risk of suicide, including all patients with a recent history of self-harm, who are treated with psychotropic drugs should receive modern, less toxic drugs and/or supplies lasting no more than 2 weeks.

1. It is important that analgesics are given regularly for chronic pain as they are more effective in preventing than relieving pain. Adequate doses of non-opioids given regularly will often make the use of opioids unnecessary.

2. Analgesics have a 'dose ceiling' with regard to efficacy, and the variable side-effect profile up to the maximum useful dose will influence the choice of a particular analgesic.

For advice on pain relief in palliative care see BNF Prescribing in Palliative Care, Joint Formulary Palliative Care Guidelines (chapter 16) and contact the medical staff at:

Mount Edgcumbe Hospice - 01726 65711

St Julia's Hospice - 01736 759070

St Luke's Hospice - 01752 401172

Guidance on other supportive treatments may be obtained from the Pain Relief Clinic at Royal Cornwall Hospital Trust - 01872 252792

1. Prophylaxis should be considered if migraine attacks occur more than twice a month. Acute treatment for attacks will still be required as preventative therapy only reduces the frequency and severity of attacks but does not eliminate completely. It is likely that it will take between 1 - 3 months for the prophylactic medicine to take full effect. Prophylactic drugs that are effective should be continued for 4 - 6 months then withdrawn (tapered over 3 - 4 weeks) to establish continued need.

2. When using propranolol for migraine prophylaxis, 10 mg twice daily may be a sufficient starting dose.

3. Atenolol although unlicensed is also commonly used.

4. Amitriptyline (unlicensed) is first line when migraine co-exists with troublesome tension-type headache, disturbed sleep, another chronic pain condition, or depression.

5. Topiramate is indicated for migraine prophylaxis in adults and should be restricted to specialist care (maximum dose 50 mg BD).

6. NICE TA260: Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. For Botulinum Toxin Type A, see section 4.9.3 or use Search function.