When migraine with aura occurs three or more times per month — especially with significant quality-of-life burden, severe symptoms, or persistent aura — acute therapy alone is insufficient. This scenario calls for structured preventive management.
Patients reaching a threshold of three or more migraine attacks per month with a negative impact on daily functioning, or those experiencing severe symptoms or persistent aura, qualify for preventive treatment. Prevention is offered alongside education and behavioural approaches, not instead of them.
The recommended strategy is preventive monotherapy with a drug of high evidentiary support. Treatment is introduced gradually — following the principle of starting at a low dose and titrating slowly — to optimise tolerability. The full selection of agents, patient-specific criteria, and the complete algorithm are available in the protocol.
DOI: 10.1177/2514183X1882337
In frequent migraine attacks or migraine patients with severe symptoms or persistent aura, migraine prevention should be offered in addition to prevention by education and behavioural therapy.
Three or more migraine attacks per month with negative impact on quality of life;
The preventive effect of the beta blockers propranolol and metoprolol, the calcium antagonist flunarizin and the anticonvulsants valproic acid and topiramate and amitriptyline are best-documented in controlled studies (Table 4).
Due to its teratogenic properties, valproic acid should not be prescribed for women of childbearing potential or only after instructions concerning reliable contraception.
Medications for migraine prevention should be given in slowly increasing doses.
Migraine prevention is considered effective when it achieves a reduction of the migraine attack frequency of 50% or more.
The effectiveness, defined as a reduction of migraine days by 50%, can be evaluated 2 months after reaching the highest tolerated dose.
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