Intended for healthcare professionals

Clinical Review

Pharmacological prevention of migraine

BMJ 2011; 342 doi: (Published 18 February 2011) Cite this as: BMJ 2011;342:d583

This article has a correction. Please see:

  1. Nathan Fenstermacher, physician assistant1,
  2. Morris Levin, co-director 1,
  3. Thomas Ward, co-director1
  1. 1Dartmouth Headache Centre, Dartmouth Hitchcock Medical Centre, Lebanon, NH 03756, USA
  1. Correspondence to: N Fenstermacher nathan.p.fenstermacher{at}

Summary points

  • Accurate diagnosis of migraine is crucial to establishing an effective treatment plan

  • Migraine cannot be cured, just prevented

  • A preventive management plan must take into account coexisting conditions and the patient’s preferences

  • Preventive treatment should aim to decrease the frequency and severity of acute attacks, make acute treatments more efficacious, and minimise adverse drug reactions

People who have migraine experience intermittent attacks of unilateral, pulsating, and moderate to severe headache with associated nausea or photophobia and phonophobia (or all these symptoms). These attacks typically start before the age of 40, often in childhood or teenage years, and occur most commonly from the second to the fourth decade of life.1 Attacks may be infrequent or frequent. Chronic migraine is diagnosed when attacks regularly occur on more than 15 days a month. Box 1 shows the International Headache Society’s classification criteria for migraine without aura.

Box 1 International Headache Society’s classification criteria for migraine without aura1

At least five attacks fulfilling criteria A-C

  • A: Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

  • B: Headache has at least two of the following characteristics:

    • Unilateral location

    • Pulsating quality

    • Moderate or severe pain intensity

    • Aggravation by, or causes avoidance of, routine physical activity

  • C: During headache at least one of the following occurs:

    • Nausea or vomiting

    • Photophobia and phonophobia

  • D Not attributed to another disorder

Recent population studies have shown the worldwide prevalence of migraine to be greater than 10%. The prevalence of migraine in the United States has been estimated at 18% for women, 6% for men, and 12% overall.2 3 Migraine clearly affects women more than men, and its aetiology also seems to have a hereditary component. The World Health Organization ranks migraine 19th on the list of diseases worldwide that cause disability.w1 In spite of recent advances in treatment options for migraine, both acute and preventive, these treatments continue …

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