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.
Key red flags
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
Establish baseline monthly migraine days, all headache days, acute use and disability, then quantify treatment response.
Management branches
Migraine burden justifies a preventive-treatment discussion.
- Confirm migraine phenotype, count baseline days and disability, assess medication overuse and agree the outcome that would make daily treatment worthwhile.
- Compare propranolol, topiramate and amitriptyline against asthma, pulse, weight, cognition, mood, sleep, overdose risk, pregnancy intention and patient preference.
Key medicines
PropranololA common start is 40 mg two or three times daily, titrated within BNF and local formulary limits to response and tolerance.
TopiramateOften start 25 mg at night and titrate slowly towards 50 mg twice daily or the lower effective tolerated dose under local guidance.