Preventive Treatment of Migraine with Brainstem Aura in Patients with Three or More Attacks per Month

Clinical Scenario

Preventive intervention is indicated when the migraine burden is high. This protocol applies when the patient's attack pattern meets any of the following criteria:

Three or more migraine attacks per month with negative impact on quality of life
Migraine attacks that regularly last longer than 72 hours
Migraine with persistent aura
Attacks unresponsive to acute therapy

Treatment Approach

Management is built around drug prevention using high-evidence substances, started at low doses and increased gradually. Multiple distinct pharmacological classes form the evidence base — the specific agents, their selection criteria, and any patient-specific restrictions are set out in full in the complete protocol.

Treatment Goal

Prevention is considered effective when migraine attack frequency is reduced by 50% or more, assessed 2 months after reaching the highest tolerated dose.

Instant Access to Structured Evidence-Based Regimens

References

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;

Migraine attacks which regularly last longer than 72 h;

The preventive effect of the beta blockers propranolol and metoprolol, the calcium antagonist flunarizin and the anti-convulsants valproic acid and topiramate and amitriptyline are best-documented in controlled studies (Table 4).

Medications for migraine prevention should be given in slowly increasing doses.

Topiramate and onabotulinumtoxinA are effective in chronic migraine with or without medication overuse.

Due to its teratogenic properties, valproic acid should not be prescribed for women of childbearing potential or only after instructions concerning reliable contraception.

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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