A 30-year-old accountant presents to your afternoon surgery to discuss the management of his migraines. He has been under quite a lot of stress at work and his migraines are occurring 4-5 times per month. His last attack was quite disabling and lasted 3 days. He currently takes a combination of ibuprofen and sumatriptan for his attacks.

1. When should preventative treatment for migraines be considered?
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The aim of preventive treatment is to reduce the frequency, severity, and duration of migraine attacks, and avoid medication-overuse headache.

Preventative treatment should be considered if

  • Migraine attacks are causing frequent disability (e.g. two or more attacks per month that produce disability lasting for 3 days or more)
  • The person is at risk of medication overuse headache (MOH) due to frequent use of acute drugs
  • Standard analgesia and triptans are either contraindicated or ineffective
  • Migraine is of an uncommon type, such as hemiplegic migraine, or migraine with prolonged aura. In these circumstances, consider referral or seek expert advice.
  1. What are the first-line treatments recommended by NICE for migraine prophylaxis?
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Topiramate or propranolol are recommended by NICE as the first-line treatments.


  • Initially 25 mg at night for 1 week, then increase in steps of 25 mg at weekly intervals. The usual dosage is 50–100 mg daily in 2 divided doses and the maximum dosage is 200 mg daily.
  • Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.



  • Initially 80 mg daily (either 40 mg twice a day, or 80 mg modified-release once a day taken in the morning or the evening). The dose may be increased to 160 mg daily, and subsequently to 240 mg daily if necessary (either in divided doses or as a single modified-release dose).
  • Propranolol is suitable for people with coexisting hypertension or anxiety. It is not suitable for people with asthma, chronic obstructive pulmonary disease, peripheral vascular disease, or uncontrolled heart failure.
  1. What alternative treatment options are recommended if these options are ineffective?
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Alternative treatment options include:

  1. When should the need for continuing migraine prevention treatment be reviewed?
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The need for continuing migraine prevention treatment should be reviewed 6 months after the start of preventive treatment.


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