Preventive therapy should be considered in patients having four or more headaches a month or at least eight headache days a month, significantly debilitating attacks despite appropriate acute management, difficulty tolerating or having a contraindication to acute therapy, medication overuse headache, patient preference, or the presence of certain migraine subtypes (i.e., hemiplegic migraine migraine with brainstem aura migrainous infarction or frequent, persistent, or uncomfortable aura symptoms).ĭivalproex (Depakote), topiramate (Topamax), metoprolol, propranolol, and timolol are effective for migraine prevention and should be offered as first-line treatment.
Nonpharmacologic therapies such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic feedback, and cognitive behavior therapy also have good evidence to support their use in migraine prevention. The complementary treatments petasites, feverfew, magnesium, and riboflavin are probably effective. Food and Drug Administration however, more studies of long-term effectiveness and adverse effects are needed. Newer agents target calcitonin gene-related peptide pain transmission in the migraine pain pathway and have recently received approval from the U.S. Acebutolol, oxcarbazepine, lamotrigine, and telmisartan are ineffective. There is limited evidence for nebivolol, bisoprolol, pindolol, carbamazepine, gabapentin, fluoxetine, nicardipine, verapamil, nimodipine, nifedipine, lisinopril, and candesartan. Medications such as amitriptyline, venlafaxine, atenolol, and nadolol are probably effective but should be second-line therapy. First-line medications established as effective based on clinical evidence include divalproex, topiramate, metoprolol, propranolol, and timolol. Identifying and managing environmental, dietary, and behavioral triggers are useful strategies for preventing migraines. Some indications for preventive therapy include four or more headaches a month, eight or more headache days a month, debilitating headaches, and medication-overuse headaches. Preventive therapy may also improve quality of life and prevent the progression to chronic migraines. Preventive medication therapy reduces migraine frequency, severity, and headache-related distress. Approximately 38% of patients with episodic migraines would benefit from preventive therapy, but less than 13% take prophylactic medications. Migraines impose significant health and financial burdens.
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