Prevention of migraine

• identifying and avoiding trigger factors can reduce the frequency of migraine attacks by up to 50%
• prophylactic therapy is indicated for recurring migraines (typically four or more attacks per month or severe functional impairment) (1)
• initial oral options include propranolol, topiramate, and amitriptyline; specialist options for refractory or chronic migraine include botulinum toxin type A and calcitonin gene-related peptide (CGRP) monoclonal antibodies (2, 3)

First-Line Oral Pharmacotherapy (NICE Guidance) (2)

Recommended Options

• consider propranolol, topiramate, or amitriptyline for migraine prevention after discussing individual benefits, risks, and suitability (2)
• if the first agent is ineffective or not tolerated, offer a trial of a second or third option unless contraindicated (2)

Important Prescribing Precautions

• topiramate: strictly contraindicated in pregnancy and in women/girls of childbearing potential unless the requirements of the Pregnancy Prevention Programme (PPP) are fully met due to teratogenicity and neurodevelopmental risks (2)
• anti-CGRP mAbs wash-out and pregnancy: anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be stopped at least 6 months prior to planned conception owing to long elimination half-lives and an increased risk of spontaneous abortion if exposed during early pregnancy (4)
• propranolol: exercise caution in patients with co-existing depression due to self-harm and toxicity risks in acute overdose (2); however, propranolol remains a safe oral option when prophylaxis is required during pregnancy (4)
• amitriptyline: adhere to safe antidepressant prescribing and structured withdrawal management guidelines (2)

Non-Pharmacological and Alternative Options (2)

• acupuncture: consider a course of up to 10 sessions over 5 to 8 weeks if oral prophylactic medications have failed, are not tolerated, or are contraindicated (2)
• dietary supplementation: advise patients that riboflavin (vitamin B2, 400 mg once daily) may reduce attack frequency and severity in some individuals (2)
• gabapentin: do not offer gabapentin for migraine prophylaxis (2)

Review and Duration (2)

• review the efficacy and ongoing need for prophylactic treatment 3 to 6 months after initiation (2)
• for patients whose migraine is well controlled on established prophylaxis, continue current treatment as required (2)

Specialist Prophylaxis Options

Botulinum Toxin Type A (3)

• indication: recommended for adults with chronic migraine (>=15 headache days per month, with at least 8 days meeting migraine criteria) that has failed to respond to at least 3 prior pharmacological trials and where medication overuse is appropriately managed (2, 3)
• stopping criteria: discontinue if headache frequency is not reduced by at least 30% after 2 treatment cycles, or if the condition converts to episodic migraine for 3 consecutive months (2, 3)

Calcitonin Gene-Related Peptide (CGRP) Inhibitors (2, 5, 6, 7)

• indications (erenumab, fremanezumab, galcanezumab, eptinezumab): recommended for adults with >=4 migraine days per month who have failed at least 3 prior preventive drug treatments (2, 5, 6, 7)
• stopping criteria: stop CGRP inhibitors after 12 weeks of therapy if migraine frequency does not decrease by (2):
  • at least 50% in episodic migraine
  • at least 30% in chronic migraine

Reference:

1. Drug and Therapeutics Bulletin. Prophylaxis of migraine. DTB. 1998;36(6):41-4.
2. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management. NICE Clinical Guideline [CG150]. Updated June 2025.
3. National Institute for Health and Care Excellence (NICE). Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. NICE Technology Appraisal [TA260]. June 2012.
4. Flatman LK, Leal LF, Leroux E, et al. Early Pregnancy Use of Anti-CGRP Monoclonal Antibodies and Propranolol and Spontaneous Abortion Risk. JAMA Neurology. Published online October 12, 2026. DOI: 10.1001/jamaneurol.2026.3573.
5. National Institute for Health and Care Excellence (NICE). Fremanezumab for preventing migraine. NICE Technology Appraisal [TA631]. June 2020.
6. National Institute for Health and Care Excellence (NICE). Galcanezumab for preventing migraine. NICE Technology Appraisal [TA659]. November 2020.
7. National Institute for Health and Care Excellence (NICE). Erenumab for preventing migraine. NICE Technology Appraisal [TA682]. March 2021.