01Role and principlesWho benefits and the main preventive aims.
Prevention aims to reduce attack frequency, severity and disability, improve response to acute treatment and restore predictability. The decision is individual: four modest attacks controlled rapidly may matter less than one prolonged hemiplegic-like episode or repeated absence from work. Establish a diary baseline over a representative period and agree what success means, commonly a meaningful reduction in monthly migraine days plus improved function and acceptable tolerability. Explain that benefit builds gradually. Review sleep regularity, meals, hydration, exercise, caffeine and triggers without imposing exhaustive avoidance or blaming the patient. Treat comorbid sleep apnoea, depression or medication overuse where relevant, but preserve migraine-specific care.
For general prevention, NICE asks clinicians to consider propranolol, topiramate or amitriptyline. Choice is driven by the person rather than a universal ranking. Propranolol may suit tremor or hypertension but is problematic in asthma, bradycardia, hypotension and some overdose-risk contexts. Amitriptyline may help sleep or another pain syndrome but causes anticholinergic effects, sedation, weight gain and cardiac toxicity in overdose. Topiramate may support weight loss but can impair word finding and concentration, cause paraesthesia, mood change, renal stones and rare acute angle closure. It has important fetal risks: for migraine prevention it is contraindicated in pregnancy and, for a woman of childbearing potential, may be used only when Pregnancy Prevention Programme conditions are fulfilled. Verify current MHRA requirements, highly effective contraception and pregnancy testing arrangements; do not rely on a generic warning.
Titrate one intervention with a planned review, unless clinical need dictates otherwise. If the first is ineffective at a tolerated dose, causes unacceptable effects or is contraindicated, switch thoughtfully to another option. Acupuncture can be considered when propranolol, topiramate and amitriptyline are unsuitable or ineffective. Specialist services can assess onabotulinumtoxinA for chronic migraine when at least three preventive medicines have failed and medication overuse is appropriately managed. NICE technology appraisals permit defined CGRP monoclonal antibodies, gepants or other agents after at least three preventives have failed or are unsuitable, with product-specific stopping rules often based on reduction in migraine days. These are not interchangeable blanket approvals: eligibility, dose, commissioning and response thresholds follow the current appraisal and local pathway.
Key points
- Discuss prevention when attacks are frequent, prolonged or disabling, acute therapy is ineffective or contraindicated, aura is troublesome, or medication overuse is developing; no single frequency threshold fits everyone.
- Record baseline monthly migraine days, all headache days, acute-treatment days and functional impact before treatment so that benefit can be judged fairly.
- NICE recommends considering propranolol, topiramate or amitriptyline after discussing preference, comorbidity, adverse effects and impact on quality of life.
- Topiramate must not be used for migraine prevention in pregnancy and requires compliance with the MHRA Pregnancy Prevention Programme in women of childbearing potential.
- Start low and titrate gradually to a tolerated evidence-based dose; an adequate trial usually requires time at the target or highest tolerated dose rather than a few days of exposure.
- Review preventive need and benefit 3–6 months after starting, using diary outcomes and adverse effects; continue, taper or switch through shared decision rather than automatically renewing.
- Riboflavin 400 mg once daily may reduce frequency and intensity for some people, but supplement quality, cost and limited comparative evidence should be discussed.
- CGRP-pathway medicines and botulinum toxin type A are specialist options under technology-appraisal criteria after failure or intolerance of multiple conventional preventives.
- Manage medication overuse and optimise acute therapy alongside prevention; a preventive prescription alone does not dismantle an entrenched high-frequency rescue cycle.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Frequent or disabling attacks, prolonged recovery, failure or contraindication of acute therapy, problematic aura or rising rescue use creates a reasonable shared-decision case for prevention.
A sustained reduction in migraine days with better function and acceptable adverse effects is more clinically useful than a small change in pain score on isolated attacks.
Word-finding difficulty, slowed thinking, paraesthesia, appetite change or mood deterioration can emerge during titration and should be actively elicited rather than awaiting spontaneous reporting.
Acute eye pain, blurred vision or halos after starting topiramate may indicate acute myopia with secondary angle closure and needs immediate eye assessment and medicine advice.
Symptomatic bradycardia, wheeze, hypotension, fatigue or exercise limitation suggests propranolol is unsafe or poorly tolerated and should prompt clinical review.
Chronic or high-frequency migraine persisting despite adequately tried conventional preventives may meet a NICE technology-appraisal pathway for botulinum toxin or a CGRP-targeting medicine.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Prospective headache diaryFirst step - Why
- Establish baseline monthly migraine days, all headache days, acute use and disability, then quantify treatment response.
- Interpretation and limitations
- Compare equivalent periods and note menstrual or work patterns; benefit should be clinically meaningful and sustained rather than based on one unusually good week.
- 02
Blood pressure, pulse and respiratory history - Why
- Assess suitability and monitoring needs before a beta blocker is selected.
- Interpretation and limitations
- Bradycardia, hypotension, conduction disease or asthma may make propranolol inappropriate; check local prescribing and relevant comorbidity advice.
- 03
Pregnancy testing and contraceptive review - Why
- Meet topiramate Pregnancy Prevention Programme safeguards and align all prevention with pregnancy intentions.
- Interpretation and limitations
- Topiramate is contraindicated for migraine prevention during pregnancy; documented programme conditions are required for women of childbearing potential.
- 04
Weight, mood and cognitive baseline - Why
- Make anticipated preventive adverse effects measurable and choose a drug compatible with the person's priorities.
- Interpretation and limitations
- Weight loss and cognitive slowing may point away from topiramate, while sedation, weight gain and anticholinergic burden may make amitriptyline undesirable.
- 05
Renal and ECG assessment when indicated - Why
- Investigate patient-specific stone, electrolyte, conduction or overdose concerns rather than testing everyone identically.
- Interpretation and limitations
- Renal-stone history affects topiramate choice; ECG review may be appropriate with cardiac history or tricyclic risk according to local policy.
04InterventionsLifestyle, treatment and escalation options.
01Shared startChoose prevention around the personFirst stepMigraine burden justifies a preventive-treatment discussion.+
- 1Confirm migraine phenotype, count baseline days and disability, assess medication overuse and agree the outcome that would make daily treatment worthwhile.
- 2Compare propranolol, topiramate and amitriptyline against asthma, pulse, weight, cognition, mood, sleep, overdose risk, pregnancy intention and patient preference.
- 3For any topiramate consideration complete current MHRA reproductive safeguards before prescribing, and select another option if programme conditions cannot be met.
- 4Start low, titrate at an agreed pace, provide adverse-effect and urgent-stop advice, and book review rather than leaving titration open ended.
02ReviewJudge an adequate preventive trialThe person has taken a preventive long enough to assess benefit or develops adverse effects.+
- 1Check actual dose, titration, adherence and time at the highest tolerated dose, alongside migraine-day and functional diary outcomes.
- 2Address remediable adverse effects and expectations, but stop or switch promptly when harms are significant or pregnancy safety changes.
- 3At 3–6 months decide jointly whether benefit justifies continuation, a cautious taper, another conventional option, acupuncture or referral.
- 4Continue to optimise acute treatment and withdraw overused medication so apparent preventive failure is not sustained by a parallel rescue cycle.
03EscalationUse specialist options within criteriaEscalationMigraine remains disabling after adequate conventional preventive trials.+
- 1Document each preventive, dose, duration, adherence, effect and reason for stopping, plus current migraine and headache-day counts.
- 2Refer through the local headache pathway for confirmation of episodic or chronic migraine and current technology-appraisal eligibility.
- 3Match botulinum toxin, CGRP monoclonal antibody or gepant selection to the exact NICE appraisal, commissioning rules, pregnancy context and comorbidity.
- 4Apply the product-specific response and stopping rule at the defined interval, avoiding indefinite specialist therapy without measured benefit.
05Medicines and treatment safetyRegimens, contraindications and review points.
Propranolol
A common start is 40 mg two or three times daily, titrated within BNF and local formulary limits to response and tolerance.Avoid in asthma and relevant bradycardia, hypotension or conduction disease; discuss fatigue and sleep effects, and consider toxicity risk in people at risk of self-harm.
Topiramate
Often start 25 mg at night and titrate slowly towards 50 mg twice daily or the lower effective tolerated dose under local guidance.Contraindicated for migraine prevention in pregnancy and subject to the MHRA Pregnancy Prevention Programme. When creatinine clearance is 70 mL/min or less, product information recommends half the usual starting and maintenance dose and slower titration; use caution in hepatic impairment and watch mood, cognition, stones, metabolic acidosis and acute ocular symptoms.
Amitriptyline
Commonly start 10 mg at night and increase gradually according to response, tolerability, age and the local headache formulary.Anticholinergic burden, sedation, weight gain, postural hypotension, arrhythmia and lethality in overdose require careful selection, limited supply where appropriate and review.
Riboflavin
NICE notes that 400 mg once daily may be effective for reducing migraine frequency and intensity in some people.Discuss cost, supplement quality, harmless urine discolouration and the need to keep measuring migraine burden; it does not replace investigation of red flags.
CGRP-pathway preventive
Use the product-specific licensed oral or injectable regimen only through the commissioned specialist pathway and current NICE technology-appraisal criteria.Products have different pregnancy, interaction, constipation, blood-pressure and hypersensitivity considerations; record baseline days and apply the exact appraisal stopping rule.
06Targets, monitoring and follow-upResponse, safety and longer-term review.
- Compare monthly migraine days, total headache days, acute-treatment days and functional impact with the documented pre-treatment baseline.
- During titration ask specifically about mood, suicidal thinking, cognition, weight, paraesthesia, sleep, pulse, wheeze, dizziness and anticholinergic effects according to drug choice.
- For topiramate, maintain the Pregnancy Prevention Programme reviews, pregnancy testing and contraception checks required by current MHRA materials.
- Review preventive efficacy and ongoing need 3–6 months after initiation and periodically thereafter; do not treat automatic repeat prescribing as review.
- For specialist therapies, record response at the technology-appraisal timepoint and stop, switch or continue according to the product-specific criterion.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Disability sets the threshold
Attack count informs but does not dictate prevention. Duration, occupational impact, aura, recovery and failure of acute treatment can justify therapy at different frequencies.
Comorbidity can choose twice
A preventive may help another condition, but apparent dual benefit should never override a contraindication such as asthma with propranolol or pregnancy risk with topiramate.
Slow titration protects adherence
Many preventives fail because early adverse effects outpace benefit. A low starting dose, planned increments and accessible review can reveal a tolerable effective dose.
Document failed trials well
Specialist eligibility often depends on adequate previous trials. Recording dose, duration, adherence, outcome and harm prevents unnecessary repetition and supports fair access.
Stopping is part of prescribing
An agreed review and taper strategy prevents years of unexamined therapy after migraine burden, reproductive plans or comorbidity has changed.
08Common pitfallsFrequent interpretation and management errors.
- 01
Starting daily prevention without a baseline diary, then being unable to distinguish benefit from ordinary fluctuation in attack frequency.
- 02
Prescribing topiramate for migraine during pregnancy or without completing the current Pregnancy Prevention Programme requirements where they apply.
- 03
Stopping every preventive after a few low doses before sufficient titration and exposure, unless adverse effects make continuation unsafe.
- 04
Choosing propranolol without asking about asthma, pulse, exercise limitation or overdose risk, because it appears familiar and inexpensive.
- 05
Referring for a named CGRP product without documenting prior trials or checking the exact current NICE appraisal and local commissioning route.
- 06
Continuing a preventive indefinitely because it appears on repeats, without measuring migraine days, function, harms or ongoing patient preference.