Migraine prevention medication: what are your options?

Migraine prevention medication (also called migraine prophylaxis) is medicine you take regularly, not just during an attack, to reduce how often migraine attacks happen and how severe they are. The newest options were developed specifically for migraine: the gepants atogepant and rimegepant, and the CGRP antibodies erenumab, fremanezumab and galcanezumab. Older preventive medicines were originally developed for other conditions such as high blood pressure, epilepsy or depression.

Who should consider migraine prevention?

Preventive treatment is worth discussing if you have migraine attacks on several days a month, if your acute medication does not work well enough, or if you are taking acute medication so often that you risk medication overuse headache. The aim is fewer migraine days, milder attacks and acute medication that works better when you do need it.

What are the newest migraine prevention medicines?

The newer medicines all target CGRP (calcitonin gene-related peptide), a protein that plays a key role in migraine attacks. There are two groups:

• Gepants: atogepant and rimegepant are tablets that block the CGRP receptor. Both can be used to prevent attacks and to treat an attack. Because they leave the body quickly, they are easy to stop if needed.
• CGRP monoclonal antibodies: erenumab, fremanezumab and galcanezumab are injections you give yourself at home under the skin with an auto-injector pen, usually every 4 weeks.

Because these medicines were designed for migraine, they tend to cause fewer side effects than older preventives. The most commonly reported side effects are mild, such as constipation, nausea or a reaction where the injection was given.

What about older preventive medicines?

Other preventive medicines exist and may be offered through your GP, including beta blockers, candesartan, topiramate, valproate and amitriptyline. They were developed for other conditions, and side effects such as tiredness, mood changes or weight gain are common. The dose is usually built up slowly, and it can take six weeks to three months before you can tell whether they help. Some people do well on them; others stop because of side effects or because the effect fades. Your GP can discuss whether one of them suits your situation.

How is the right medicine chosen?

The choice depends on your migraine pattern, your medical history, other medicines you take, and plans such as a pregnancy. A migraine specialist will weigh these with you, explain what to expect and agree when to review whether the treatment is working.

In the UK, NICE recommends some of the newer medicines on the NHS in specific circumstances, usually after at least three other preventive treatments have not worked.

How is chronic migraine managed?

Chronic migraine means headache on 15 or more days a month for more than three months, with migraine features on at least 8 of those days. Management usually combines preventive treatment, careful use of acute medication (to avoid medication overuse headache) and regular review. The CGRP antibodies and gepants are used in both episodic and chronic migraine.

How do you know if preventive treatment is working?

Keeping a headache diary helps. Note your migraine days, how severe they are and which acute medication you take. Comparing the months before and after starting treatment shows whether the number of migraine days has fallen. A common goal is to at least halve the number of migraine days. Your migraine specialist will review this with you and decide whether to continue, adjust or switch treatment.

Finding the right prevention for you

Finding the right preventive treatment can take some time, but with the right support many people have far fewer migraine days. Read more about preventive medication and our treatment, take the migraine test, or see how to start with a migraine specialist online.