Preventive Treatment Options for Migraines Without Aura

Indications for Preventive Therapy

The American Academy of Neurology recommends preventive treatment for patients who experience two or more migraine attacks per month with disability lasting 3 or more days 3
The American Headache Society suggests considering preventive treatment when patients use acute rescue medications more than twice per week 4
Preventive treatment should be considered in patients with failure of or contraindications to acute treatments, according to the American College of Physicians 3
The American Academy of Neurology recommends considering preventive treatment in patients with uncommon migraine conditions, such as hemiplegic migraine 4

The American Heart Association recommends metoprolol (50-100 mg twice daily or 200 mg modified-release once daily) as a first-line preventive medication for migraine prophylaxis 1
The American Academy of Neurology suggests atenolol (25-100 mg twice daily) as a first-line preventive medication for migraine prophylaxis 1
The European Society of Cardiology recommends bisoprolol (5-10 mg once daily) as a first-line preventive medication for migraine prophylaxis 1
The American Academy of Neurology recommends candesartan (16-32 mg daily) as a first-line preventive medication for migraine prophylaxis 1, 2
The American Academy of Neurology suggests topiramate (50-100 mg daily) as a first-line preventive medication for migraine prophylaxis 1, 2

The American Academy of Neurology recommends amitriptyline (10-100 mg at night) as a second-line preventive medication for migraine prophylaxis 1, 3
The American Headache Society suggests flunarizine (5-10 mg once daily) as a second-line preventive medication for migraine prophylaxis 1
The American Academy of Neurology recommends sodium valproate (600-1,500 mg once daily) as a second-line preventive medication for migraine prophylaxis, but notes it is absolutely contraindicated in women of childbearing potential 1

The American Academy of Neurology recommends CGRP monoclonal antibodies, such as erenumab (70 or 140 mg subcutaneous once monthly), as a third-line preventive medication for migraine prophylaxis 1, 6
The American Headache Society suggests onabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) as a third-line preventive medication for migraine prophylaxis 1

The American Academy of Neurology recommends starting with a low dose and increasing slowly until benefits are achieved or limited by side effects 5, 2
The American Headache Society suggests allowing an adequate trial period of 2-3 months before determining efficacy 5, 2
The American Academy of Neurology recommends monitoring for effectiveness using headache calendars to track attack frequency, severity, and migraine-related disability 1, 2

The American Academy of Neurology recommends considering non-pharmacological options, such as neuromodulatory devices, biobehavioral therapy, and acupuncture, as adjuncts to medication or when medications are contraindicated 6