Migraine Headache Prophylaxis

Moreland, Paige MD
Gaffney, Brody MD
Lanham, Jason S. MD, MA

Author Information

PAIGE MORELAND, MD, is a staff physician in family medicine at General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri.

BRODY GAFFNEY, MD, is a staff physician in family medicine at Blanchfield Army Community Hospital, Fort Campbell, Tennessee.

JASON S. LANHAM, MD, MA, FAAFP, is an associate professor in the Department of Family and Community Medicine at the Medical College of Georgia at Augusta University, Augusta.

Author disclosure: No relevant financial relationships.

This review updates previous articles on this topic by Ha and Gonzalez and Modi and Lowder.

Data Sources: A PubMed search was completed in Clinical Queries using the key terms migraine, prophylaxis, and prevention. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Essential Evidence Plus, POEMs, the Cochrane database, DynaMed, and UpToDate were also searched. Consensus guidelines from national and international sources were individually searched. Whenever possible, if studies used race and/or gender as patient categories but did not define how these categories were assigned, they were not included in our final review. Search date: February 2025.

The views expressed are those of the authors and do not reflect the official policy of the General Leonard Wood Army Community Hospital, Blanchfield Army Community Hospital, US Army, US Department of Defense, or US government.

American Family Physician 111(5):p 443-450, May 2025.

Migraine headaches are a debilitating condition that affects approximately 1% of the US population. Goals of migraine prophylaxis include reduction in headache severity and frequency, improved response to acute treatment, fewer days with disability, improvement in quality of life, and empowerment of patients with a sense of control over the condition. Indications for consideration of preventive therapy include frequent headaches, failure of or contraindication to acute treatments, overuse of acute treatments, and patient preference. First-line medications include propranolol, metoprolol, topiramate, divalproex, valproate, and calcitonin gene-related peptide receptor antagonists. However, use of calcitonin gene-related peptide receptor antagonists is limited by cost and insurance coverage. Amitriptyline and venlafaxine are considered second-line medications due to a greater number of adverse events and less supporting evidence, respectively. OnabotulinumtoxinA (Botox) injection is approved for chronic migraine prophylaxis. It is as effective as other medications, is well tolerated, and has lower discontinuation rates than other drugs. Common migraine triggers include alcohol, anxiety, dehydration, excessive caffeine, eye strain, hunger, sleep deprivation, and stress. Physicians should recommend identification and management of migraine triggers. Cognitive behavior therapy, acupuncture, neural stimulators, and exercise are supported by varying levels of evidence and can be used individually or in combination with pharmacotherapy. Alternative agents, including feverfew, magnesium, and melatonin, have shown effectiveness and are generally well tolerated.