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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Migraine prevention

Neurology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Preventive treatment must not obscure urgent investigation of a first thunderclap episode, persistent deficit, papilloedema, pregnancy-related severe change or other secondary feature. New severe depression, suicidal thoughts, symptomatic bradycardia, acute glaucoma symptoms, severe rash or pregnancy exposure to a restricted teratogenic medicine needs prompt assessment.

Synopsis

Choose and review preventive migraine treatment through shared decisions, use measurable outcomes and reproductive safeguards, and escalate appropriately to specialist CGRP or botulinum options.

  • 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.

    • Key red flags

    Topiramate ocular emergency

    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.

    Investigation priorities

    01
    Prospective headache diaryFirst step

    Establish baseline monthly migraine days, all headache days, acute use and disability, then quantify treatment response.

    Management branches

    Shared startChoose prevention around the person

    Migraine burden justifies a preventive-treatment discussion.

    1. Confirm migraine phenotype, count baseline days and disability, assess medication overuse and agree the outcome that would make daily treatment worthwhile.
    2. Compare propranolol, topiramate and amitriptyline against asthma, pulse, weight, cognition, mood, sleep, overdose risk, pregnancy intention and patient preference.
    3. For any topiramate consideration complete current MHRA reproductive safeguards before prescribing, and select another option if programme conditions cannot be met.
    4. Start low, titrate at an agreed pace, provide adverse-effect and urgent-stop advice, and book review rather than leaving titration open ended.

    Key medicines

    PropranololA 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.
    TopiramateOften 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.
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    Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE CG150 migraine prevention recommendationsConventional preventive choice, review, acupuncture and riboflavin.
    • MHRA topiramate pregnancy prevention measuresBinding reproductive risk controls for migraine prevention.
    • NICE TA260 botulinum toxin for chronic migraineEligibility, prior preventive failures and response requirements.
    • NICE TA973 atogepant for preventing migraineCGRP-pathway eligibility and stopping criteria.
    • BNF migraine treatment summaryDosing, contraindications and monitoring for preventive medicines.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom