Migrainee when start prophylactic treatment

Clinical answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 28 April 2026Updated: 28 April 2026 Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

Prophylactic treatment for migraine should be considered in adults who are not pregnant or breastfeeding if attacks are frequent or prolonged and severe despite appropriate acute treatment, or if the person is at risk of medication overuse headache.

Before initiating prophylaxis, a full discussion with the patient about benefits and risks, preferences, comorbidities, risk of adverse events, and the impact of migraine on quality of life should occur.

Common prophylactic options offered include topiramate or propranolol after discussing their benefits and risks, including considerations for women of childbearing potential regarding topiramate. Amitriptyline may be considered based on patient preference and clinical context.

Prophylactic treatment should not be initiated in primary care for pregnant or breastfeeding women or children; specialist advice is required for these groups.

The need for continuing prophylaxis should be reviewed after 6 months of treatment.

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