Preventative Treatment for Migraine: Overview & Approach


The goal of preventive treatment is the reduction of the frequency, duration, and severity of migraine episodes. There are a number of pharmacologic and nonpharmacologic treatment options for the prevention of migraine.[1]

Pharmacologic Preventive Options

Pharmacologic preventive treatment is indicated in instances where recurring migraine significantly impacts the individual’s daily routine despite the use of acute therapy, where acute treatments are contraindicated, have failed, have caused troublesome side effects, or have been overused, and according to patient preference (ie, where a patient desires to prevent migraine episodes).[1]

Pharmacologic preventive treatment should also be considered in uncommon migraine conditions, including hemiplegic migraine, basilar type migraine, migraine with prolonged aura, and migraine infarction, to prevent neurologic damage.[1] Short-term migraine prophylaxis may also be used in instances of menstrual migraine.[2]

Pharmacologic preventive options typically include antihypertensives, antidepressants, anticonvulsants/antiepileptics, and other drugs (eg, botulinum toxin type A, pizotifen), and various medicinal herbs and vitamins.[3] The relative efficacy and safety of these various agents is shown in Table 1.

Table 1. Pharmacologic Options for Preventing Migraine
High Efficacy: low-to-moderate AEs
  • Propranolol
  • Timolol
  • Amitriptyline
  • Valproate
  • Flunarizine
Low Efficacy: low-to-moderate AEs
  • NSAIDs: aspirin, flurbiprofen, ketoprofen, naproxen sodium
  • Beta-blockers: atenolol, metoprolol, nadolol
  • Calcium channel blockers: verapamil
  • Anticonvulsants: gabapentin
  • Other drugs: fenoprofen, vitamin B2, pizotifen
Unproven efficacy: low-to-moderate AEs
  • Antidepressants: doxepin, nortriptyline, imipramine, protriptyline, venlafaxine, fluvoxamine, mirtazapine, paroxetine, protriptyline, sertraline, trazodone
Proven low or no efficacy
  • Acebutolol, carbamazepine, clomipramine, clonazepam, indomethacin, lamotrigine, nabumetone, nicardipine, nifedipine, pindolol, botulinum toxin
Adapted from Silberstein SD. Neurol Clin. 2009;27:429-43.

Principles of Pharmacologic Preventive Treatment

The pharmacologic agent used in migraine prophylaxis should be initiated at a low dose and titrated upward slowly until therapeutic effect is achieved, side effects become intolerable, or the highest recommended dose for the drug is reached. An adequate trial of the chosen drug should be given, as optimal benefit may not be achieved until 6 months in some cases. Medication overuse of acute migraine treatments should be avoided and special care should be given to avoid drugs that are contraindicated in comorbid illnesses. In selecting drug options, comorbidity should be considered, as selected drugs may be effective in treating both migraine and the comorbid disorder. Treatment should be re-evaluated, and, where possible, tapered or discontinued following a period of sustained remission (6 to 9 months). In cases of pregnancy, only medications with low potential for risk to the fetus should be used. Female patients of childbearing age should be made aware of potential risks associated with treatment. Preventive therapy is typically recommended for only 6 to 9 months.[3]

Nonpharmacologic Preventive Options

American Academy of Neurology 2000 evidence-based guidelines recommend cognitive and behavioral interventions for migraine prevention, including relaxation training with and without thermal biofeedback, electromyographic biofeedback, and cognitive-behavioral therapy. According to these recommendations, behavioral therapy may be used in combination with pharmacologic treatments. At the time of these recommendations, other nonpharmacologic approaches (eg, acupuncture, transcutaneous electrical nerve stimulation, spinal manipulation, hyperbaric oxygen) could not be recommended on the basis of existing evidence.[1]

Nonpharmacologic prevention options may be used by patients who prefer nonpharmacologic treatment options, fail to respond to or experience intolerable side effects associated with drug treatments, have medical contradindications to drug treatments, have a history of acute migraine drug treatment or analgesic overuse, or have significant stress or deficient skills in coping with stress.[1]

A variety of nonpharmacologic preventive treatment options are available (Table 2).[4] These interventions have varying degrees of evidence to support their effectiveness in migraine prophylaxis.

Table 1. Nonpharmacologic Treatment Options for Migraine
Interventions targeting trigger factors 
  • Dietary modifications (avoiding foods that trigger migraine)
  • Good sleep hygiene
  • Stress avoidance
  • Avoidance of glare and other sensory stimuli
  • Avoidance of alcohol and caffeine
Behavioral interventions 
  • Biofeedback
  • Cognitive-behavioral therapy
  • Relaxation techniques
  • Aerobic exercise
  • Hypnosis
  • Removal of muscle or nerve tissue at trigger site
  • Closure of right-to-left cardiac shunt
Alternative interventions 
  • Spinal manipulation
  • Hyperbaric oxygen
  • Homeopathy
  • Acupuncture
Data from Sándor P, Áfra J. Curr Pain Headache Rep. 2005;9:202-205.