Migraine Prevention with Aura

First-Line Medications

The American College of Physicians recommends propranolol (80-240 mg/day) as a first-line treatment for migraine prevention, with consistent evidence of efficacy 1
The American Academy of Neurology recommends metoprolol (50-100 mg twice a day or 200 mg of modified release once a day) as a first-line treatment for migraine prevention 2
The American Headache Society recommends topiramato (50-100 mg/day) as a first-line treatment for migraine prevention, with good evidence of efficacy 1, 2
The American College of Physicians recommends divalproex sodium and valproate sodium (600-1500 mg once a day) as first-line treatments for migraine prevention, with good evidence of efficacy 1, 2
The American Academy of Neurology warns that valproate is absolutely contraindicated in women of childbearing age due to the risk of teratogenicity, including neural tube defects 1, 2

The American Academy of Neurology recommends amitriptilina (10-100 mg at night) as a second-line treatment for migraine prevention, with consistent evidence of efficacy 1, 2
The American Headache Society recommends flunarizina (5-10 mg once a day) as a second-line treatment for migraine prevention 2

The American Academy of Neurology recommends erenumab (70 or 140 mg subcutaneously once a month) as a third-line treatment for migraine prevention, after failure of first- and second-line oral preventives 2, 3
The American Headache Society recommends onabotulinumtoxinA for chronic migraine (≥15 days of headache per month) 2, 3

The American College of Physicians recommends naproxen or naproxen sodium for migraine prevention, with modest effect according to meta-analysis 1
The American Academy of Neurology recommends methysergide for migraine prevention, with solid evidence of efficacy, but warns of the risk of retroperitoneal and retropleural fibrosis with prolonged administration without interruption 1

The American Academy of Neurology recommends initiating preventive treatment for migraine with two or more attacks per month with disability lasting 3 or more days 2
The American Headache Society recommends a strategy of starting with low doses and slowly increasing until benefits are achieved or until side effects limit the increase 2
The American Academy of Neurology recommends monitoring effectiveness using headache calendars to track frequency, severity, and disability related to migraine 2

The American Academy of Neurology recommends considering neuromodulatory devices, behavioral therapy, and acupuncture as complements to medication or when medications are contraindicated 2