PURPOSE OF REVIEW: This article reviews the preventive therapy of migraine, 
including indications, strategies for use, and available treatments.
RECENT FINDINGS: Lifestyle modifications and migraine trigger avoidance are 
recommended as preventive measures for all individuals with migraine. The 
decision to recommend additional migraine preventive therapy should consider the 
frequency of migraine attacks and headaches, extent of migraine-associated 
disability, frequency of using acute migraine treatments and the responsiveness 
to such treatments, and patient preferences. Additional therapies include 
prescription medications, nutraceuticals, neurostimulation, and behavioral 
therapy. Considering evidence for efficacy and the risk of potential side 
effects and adverse events, treatments with the most favorable profiles include 
(in alphabetical order): amitriptyline, beta-blockers (several), biofeedback, 
candesartan, coenzyme Q10, cognitive-behavioral therapy, magnesium citrate, 
onabotulinumtoxinA (for chronic migraine only), relaxation therapy, riboflavin, 
and topiramate. In addition, erenumab, a calcitonin gene-related peptide (CGRP) 
receptor monoclonal antibody, received approval from the US Food and Drug 
Administration (FDA) for the prevention of migraine in May 2018.
SUMMARY: Successful migraine preventive therapy reduces the frequency and burden 
of attacks while causing limited side effects. Individual treatment 
recommendations are determined based upon evidence for efficacy, side effect and 
adverse event profiles, medication interactions, patient comorbidity, costs, and 
patient preferences. Patients must be counseled on reasonable expectations for 
their preventive therapy and the importance of adhering to the recommended 
treatment plan for a period of time that is sufficient to determine outcomes.