Prevention of migraine

Identifying and avoiding trigger factors can reduce the frequency of migraine attacks by up to 50%.

Migraine recurring four or more times per month should be treated prophylactically (1). This is because prophylactic agents only have limited success and risk chronic side effects. Also, 5HT1 agonists can more effectively deal with many attacks than previous acute treatments.

NICE suggests that (2):

• Migraine with or without aura
  • consider propranolol, topiramate or amitriptyline for migraine prevention after a full discussion of the benefits, risks and suitability of each option, including the potential benefit in reducing migraine recurrence and severity. Take into account the following factors and include them in the discussion if relevant:
    • people with depression and migraine could be at an increased risk of using propranolol for self-harm. Use caution when prescribing propranolol, to minimise the risk of harm from toxicity and rapid deterioration in overdose
    • topiramate should not be used for migraine prophylaxis in pregnancy, or in women able to have children unless the conditions of the Pregnancy Prevention Programme are fulfilled
    • for amitriptyline, take into account the advice on safe prescribing of antidepressants and managing withdrawal
  • if the first treatment tried does not work or is not tolerated, discuss trying a second option and then the remaining option, unless unsuitable because of safety concerns
    
    
• do not offer gabapentin for the prophylactic treatment of migraine
  
  
• if propranolol, topiramate and amitriptyline have not worked or are not tolerated or are unsuitable because of safety concerns, consider a course of up to 10 sessions of acupuncture over 5 to 8 weeks according to the person's preference, comorbidities and risk of adverse event
  
  
• for people who are already having treatment with another form of prophylaxis, and whose migraine is well controlled, continue the current treatment as required
  
  
• review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment
  
  
• advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people
  
  
• review the need for continuing migraine prophylaxis 3 to 6 months after starting prophylactic treatment

Notes:

• Migraine prophylaxis with botulinum toxin (3)
  • Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine (defined as headaches on at least 15 days per month of which at least 8 days are with migraine):
    • that has not responded to at least three prior pharmacological prophylaxis therapies and whose condition is appropriately managed for medication overuse
    • stop botulinum toxin type A if the frequency of headache days per month does not reduce by at least 30% after 2 treatment cycles, or if their condition has changed to episodic migraine for 3 consecutive months (2)
      
• Migraine prophylaxis with fremanezumab (4)
  • fremanezumab is recommended as an option for preventing migraine in adults, only if:
    • the migraine is chronic, that is, 15 or more headache days a month for more than 3 months with at least 8 of those having features of migraine
    • at least 3 preventive drug treatments have failed
      
• Migraine prophylaxis with galcanezumab (5)
  • galcanezumab is recommended as an option for preventing migraine in adults, only if:
    • they have 4 or more migraine days a month
    • at least 3 preventive drug treatments have failed
      
• Migraine prophylaxis with erenumab (6)
  • erenumab is recommended as an option for preventing migraine in adults, only if:
    • they have 4 or more migraine days a month
    • at least 3 preventive drug treatments have failed
    • the 140mg dose of erenumab is used
      
• with respect to calcitonin gene-related peptide [CGRP] inhibitors (2)
  • stop CGRP inhibitors after 12 weeks of treatment if the frequency of migraines does not reduce by:
  • at least 50% in episodic migraine
  • at least 30% in chronic migraine

For comprehensive details of prophylaxis of migraine see BNF.

Reference:

1. Drug and Therapeutics Bulletin (1998); 36(6):41-4.
2. NICE (June 2025). Headaches in the over 12s
3. NICE (June 2012). Botulinum toxin type A for the prevention of headaches in adults with chronic migraine.
4. NICE (June 2020). Fremanezumab for preventing migraine
5. NICE (November 2020). Galcanezumab for preventing migraine.
6. NICE (March 2021).Erenumab for preventing migraine