Migraine Prevention (Prophylaxis)

Recurrent migraine significantly impairs the quality of life and the patient's functionality, despite prompt treatment of acute attacks demands prophylactic treatment to be provided to the patients. Medication should be started on a low dose with adequate monitoring for 2-3 months. The safest drug to use in pregnant is metoprolol. This chapter emphasizes prophylactic treatment in migraine patients and also gives insight into preferred drugs to be used

Primary Category
Headache & Pain
Secondary Category


  • Recurrent migraines can be functionally impairing and can adversely effect quality of life
  • After treating migraines acutely, patients should be evaluated for preventive therapy

Goals of Preventive Therapy

  • Reduce attack severity, frequency, and duration
  • Improve function and quality of life
  • Increase responsiveness to acute headache therapy
  • Improve cost-effectiveness of migraine treatment

Indications of Preventive Therapy

  • Recurrent migraine that significantly impairs the quality of life and the patient's functionality, despite prompt treatment of acute attacks
  • Frequency of migraine attacks ≥1
  • Frequency of acute headache medication use ≥2 days/week
  • Failure of, contraindications to, or severe side effects from acute migraine therapy
  • Overuse of acute medication
  • Presence of special circumstances such as hemiplegic or basilar migraine, or attacks with risk of permanent neurological injury
  • Patient preference

Principles of Preventive Therapy

  • Start with a low dose and increase slowly
  • Use an adequate trial of 2 to 3 months
  • Avoid medication interaction or contraindications
  • Monitor with headache diary
  • Monitor for overuse of medication
  • Consider comorbid conditions
  • Consider combination preventive therapy in refractory patients
  • Wean-off medication when headaches are under control

Types of Preventive Treatments

Preventive Medications

Table 1: First-Line Drugs

25-100 mg
Twice Daily
20-120 mg
Twice Daily
5-10 mg
Once Daily
50-200 mg
Twice Daily
Valproic Acid
500-1500 mg
Twice Daily
2.5 mg
Twice Daily
550 mg
Twice Daily
Mefenamic Acid
250-500 mg
Twice Daily

Table 2: Second-Line Drugs

25-100 mg
Once Daily
Butterbur Root (Petasites)
75 mg
Twice Daily
300-1600 mg
Three Times Daily
75-225 mg
Once Daily
Vitamin B2
400 mg
Once Daily
600 mg
Once Daily
5-10 mg
Once Daily
20 mg
Once Daily
100 mg
Once Daily
Anti-calcitonin gene-related peptide (CGRP) therapies (e.g. Fremanezumab, Erenumab) are monoclonal antibodies designed specifically for treatment and prevention of migraine. Anti-CGRP therapies work by blocking CGRP from attaching to its receptor, thereby blocking the pain signal. These have fewer side effects as compared to traditional medications.

Behavioral Therapy


  • Patient preference
  • Poor tolerance to drugs
  • Failure of response or contraindications to medication
  • Pregnant or nursing mothers
  • Medication overuse
  • Significant stress or poor coping mechanisms


  • Relaxation training
  • Cognitive behavioral training
  • Biofeedback therapy

Lifestyle Changes

  • Good sleep hygiene
  • Proper hydration
  • Regular exercise
  • Effective stress management
  • Avoidance of triggers
  • Reduction or elimination of caffeine from diet
Caffeine has a protective effect when used as acute treatment of migraine whereas, chronic caffeine consumption has been linked to increasing the burden of migraine.


  • Vitamin B2 (Riboflavin); 400 mg daily
  • Magnesium; 400-500 mg daily
  • Co-enzyme Q10; up to 100 mg tds
  • Vitamin D; 50,000 IU per week
  • Melatonin; 3 mg daily
  • Feverfew (Tanacetum Parthenium)
  • Omega-3 fatty acids

Preventive Treatment of Menstrual Migraine

  • Peri-menstrual use of standard preventive drugs
  • Peri-menstrual use of non-standard preventive drugs
    • NSAIDs
    • Ergot alkaloids
    • Triptans
    • Magnesium
  • Hormonal Therapy
    • Combined oral contraceptives
    • Estrogens
    • Danazol or other synthetic androgens
    • Selective estrogen receptor modulators (e.g. Tamoxifen)
    • GnRH analogues (medical oophorectomy)
  • Dopamine agonists (e.g. Bromocriptine)

Migraine Prevention during Pregnancy

  • Safest drug to use is Metoprolol
  • Magnesium and non-drug modalities such as relaxation techniques, biofeedback, and acupuncture can be also be used


  • Migraine prophylaxis is a relatively safe and effective method of reducing attack frequency and, hence, the affliction of migraine.
  • The drugs of first choice are the beta blockers; propranolol and metoprolol, flunarizine, and the anticonvulsant drugs; valproic acid and topiramate.
  • The second-line drugs are, among others, amitriptyline, naproxen, butterbur root, gabapentin, and magnesium.
  • Prophylactic treatment can even be given for subtypes of migraine, migraine during pregnancy, chronic migraine, and menstrual migraine.

Further Reading


  1. Migraine prophylaxis - StatPearls - NCBI bookshelf. (2020, October 27). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK507873/
  1. Preventive pharmacotherapy in migraine (2013, November 21). American Headache Society. https://doi.org/10.1111/head.12273
  1. Bigal, M. E., Krymchantowski, A. V., & Rapoport, A. M. (2004). Prophylactic migraine therapy: Emerging treatment options. Current Pain and Headache Reports, 8(3), 178-184. https://doi.org/10.1007/s11916-004-0049-1
  1. Evers, S. (2008). Treatment of migraine with prophylactic drugs. Expert Opinion on Pharmacotherapy, 9(15), 2565-2573. https://doi.org/10.1517/14656566.9.15.2565
  1. Yoon, M. S., Savidou, I., Diener, H. C., & Limmroth, V. (2005). Evidence-based medicine in migraine prevention. Expert Review of Neurotherapeutics, 5(3), 333-341. https://doi.org/10.1586/14737175.5.3.333
  1. Alstadhaug, K. B., & Andreou, A. P. (2019). Caffeine and primary (Migraine) headaches—Friend or foe? Frontiers in Neurology, 10. https://doi.org/10.3389/fneur.2019.01275
  1. Spotlight on: Nutraceuticals. (2020, June 15). American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/nutraceuticals/
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Muhammad Roshan Asghar MD

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ECFMG Certified. Research Associate at NeuroCare.AI Academy

Junaid Kalia MD

Written by

Junaid Kalia MD

Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy

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