Migraine Prevention (Prophylaxis)

Muhammad Roshan Asghar (1), Muhammad Umair (1), Dr. Junaid Kalia (2)
1 - Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Lahore
2 - Founder, AINeuroCare


  • 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

First-Line Drugs
25-100 mg
Twice Daily
20-120 mg
Twice Daily
5-10 mg
Once Daily
50-200 mg
Twice Daily
500-1500 mg
Twice Daily
550 mg
Twice Daily
250-500 mg
Twice Daily

Table 2: Second-Line Drugs

Second-Line Drugs
25-100 mg
Once Daily
300-1600 mg
Three Times Daily
75-225 mg
Once Daily
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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