What Is Chronic Migraine Prevention?
Chronic migraine prevention is ongoing treatment that aims to lower the number of headache days, and make attacks less severe, in people with chronic migraine. Chronic migraine means headaches on at least 15 days a month for more than 3 months, with migraine features on at least 8 of those days.
Preventive medicine is used on a regular schedule to stop attacks before they start. Taken regularly, it may reduce the number of migraine headaches, but it rarely eliminates them. There is no cure for migraine.
Chronic Migraine Prevention at a Glance
| What it treats | Chronic migraine: headaches on 15 or more days a month for more than 3 months |
|---|---|
| How it works | Lowers how often attacks happen. Some medicines block CGRP, a protein involved in migraine pain. |
| How it's given | Injections every 12 weeks (Botox), injections or IV infusions monthly or quarterly (CGRP antibodies), or daily tablets |
| Time to work | Improvement may appear in 6 to 8 weeks. Full effect can take up to 6 months. |
| Common side effects | Depend on the treatment. Neck pain was the most frequent with Botox in trials. Nausea, constipation and tiredness are most common with atogepant. |
| FDA status | Botox is FDA-approved to prevent headaches in adults with chronic migraine. Atogepant (Qulipta) is approved to prevent episodic or chronic migraine in adults. |
How Does Chronic Migraine Prevention Work?
Chronic migraine prevention works by using regular medicines, injections, non-drug therapies and daily habits to make migraine attacks less frequent or less severe.
- CGRP-targeting medicines: CGRP is a protein that helps send pain signals and rises during attacks. Monoclonal antibodies (erenumab, fremanezumab, galcanezumab and eptinezumab) and gepants (rimegepant and atogepant) block this pathway.
- OnabotulinumtoxinA (Botox): 155 units, given as small injections divided across 7 head and neck muscle areas, repeated every 12 weeks.
- Older oral medicines: anticonvulsants, beta-blockers, calcium channel blockers and some antidepressants.
- Non-drug therapy: cognitive behavioral therapy, biofeedback, relaxation therapy and nerve-stimulation devices.
- Daily habits: regular exercise, regular meals, enough water and a consistent sleep schedule.
Who Is Chronic Migraine Prevention For?
Chronic migraine prevention is for people with 15 or more headache days a month, but clinicians may consider preventive treatment at much lower headache frequencies. Clinicians consider prevention when someone has:
- Four or more headaches a month, or at least 8 headache days a month
- Disabling attacks despite acute treatment
- Trouble tolerating acute medicines, or a reason not to take them
- Medication overuse headache
- A personal preference for prevention
Preventing episodic migraine may also keep it from becoming chronic. The American Headache Society's 2024 position statement says CGRP-targeting therapies should be considered a first-line option, alongside older first-line medicines, without first failing other preventive drug classes.
What to Expect During Treatment
Chronic migraine prevention starts with an evaluation, followed by a trial of treatment and regular follow-up.
Before
Your clinician reviews your history and does physical and neurological exams. Bring a headache journal noting each headache's timing, length, medicines and sleep.
During
Older oral medicines usually start at the lowest effective dose, which is raised every 2 to 4 weeks as needed. Atogepant is a tablet taken once a day. CGRP antibodies are self-injected under the skin or given by IV infusion.
After
Success is usually defined as a 50% drop in headache attacks or days, shorter attacks, or a better response to acute medicine. If a medicine doesn't help after 2 months, your clinician may consider a change. If headaches stay controlled for 6 to 12 months, your clinician may slowly taper the medicine.
How Well Does Chronic Migraine Prevention Work?
Chronic migraine prevention reduces headache days for many people, but rarely to zero. In two placebo-controlled Botox trials, headache days fell by 7.8 and 9.2 days per 28 days at week 24, versus 6.4 and 6.9 with placebo. In the atogepant chronic migraine trial, monthly migraine days fell by 6.9 over 12 weeks, versus 5.1 with placebo, from about 19 days at the start.
Risks and Side Effects of Chronic Migraine Prevention
Chronic migraine prevention side effects depend on the treatment.
- Botox: neck pain (9% vs. 3% with placebo), drooping eyelid, muscle stiffness and muscle weakness. A boxed warning notes that the toxin's effect can spread beyond the injection site. Swallowing or breathing trouble can be life-threatening, so seek immediate medical care if it happens.
- Atogepant: nausea, constipation and tiredness or sleepiness. New or worse high blood pressure, Raynaud's phenomenon and allergic reactions can occur.
- Older oral medicines: fatigue (beta-blockers), tingling (topiramate) or drowsiness and dry mouth (amitriptyline).
Who Shouldn't Use Certain Treatments
- Botox: people allergic to any botulinum toxin product or with an infection at the injection site
- Atogepant: people allergic to it; avoid with severe liver impairment. Animal data suggest it may harm a fetus.
- Divalproex and topiramate: avoid in pregnancy because of birth defect risks.
- Beta-blockers: avoid with asthma, COPD or a slow heart rate.
Chronic Migraine Prevention vs. Acute Migraine Treatment
Chronic migraine prevention lowers how often attacks happen, while acute treatment relieves an attack that has already started.
| Preventive treatment | Acute treatment | |
|---|---|---|
| Goal | Fewer, milder attacks | Stop pain and symptoms of one attack |
| When used | On a schedule, whether or not you have a headache | As soon as symptoms begin |
| Examples | Botox, CGRP antibodies, atogepant, beta-blockers, topiramate | Triptans, ergots, ibuprofen, acetaminophen, ubrogepant, rimegepant |
| Overuse risk | Medication overuse headache is one reason to start prevention | Using certain pain medicines on 10 or more days a month may cause medication overuse headache |
Chronic Migraine Prevention at GENEVA
At GENEVA Primary Care & Med Spa in Alpharetta, GA, a provider evaluates your headache pattern, history and current medicines. Based on that evaluation, your provider recommends treatment at GENEVA or a referral to a specialist.
You can raise migraine concerns during a primary care visit or as part of chronic disease management. GENEVA serves patients from Alpharetta, Johns Creek, Milton, Roswell and Cumming.
Related Terms
Chronic Migraine Prevention FAQs
What is the best preventive treatment for chronic migraine?
No single preventive treatment is best for everyone with chronic migraine; the right choice depends on your health, other conditions and preferences. Botox and atogepant are FDA-approved for chronic migraine prevention in adults. The American Headache Society's 2024 statement says CGRP-targeting medicines, including erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant and atogepant, can be first-line choices. Older pills such as topiramate or propranolol may suit people who also have seizures or high blood pressure. A headache diary helps track what works.
How long does chronic migraine prevention take to work?
Chronic migraine prevention usually takes weeks to show benefit, and full effect can take months. With preventive medicines, improvement may appear in 6 to 8 weeks, but full effect can take up to 6 months. In Botox trials, headache days dropped more than with placebo at most check-ins from week 4 onward. Your clinician may consider switching if there is no response after 2 months. Track your headache days while you wait.
Is Botox FDA-approved for chronic migraine?
Yes, Botox (onabotulinumtoxinA) is FDA-approved to prevent headaches in adults with chronic migraine, defined on the label as 15 or more days a month with headache lasting 4 hours a day or longer. The recommended dose is 155 units, injected across 7 head and neck muscle areas every 12 weeks. Its safety and effectiveness have not been established for episodic migraine (14 or fewer headache days a month). Neck pain was its most frequent side effect in chronic migraine trials.
Can chronic migraine be cured?
No, chronic migraine can't be cured, but preventive treatment can reduce how often attacks happen and how severe they are. The FDA notes that regular preventive medicines may reduce the number of migraine headaches but rarely eliminate them completely. Benefits can fade after stopping: one meta-analysis found monthly migraine days rose by 4.43 three months after stopping CGRP antibodies, compared with just before stopping, though migraine burden stayed below pretreatment levels. If headaches stay controlled for 6 to 12 months, your clinician may discuss slowly tapering treatment.
What is the difference between chronic migraine and medication overuse headache?
Chronic migraine is a migraine disorder with headaches on 15 or more days a month, while medication overuse headache is caused by taking headache medicine too often. Medication overuse headache is defined by regular use of triptans, ergots or opioids on 10 or more days a month, or acetaminophen or NSAIDs on 15 or more days a month, for more than 3 months. These headaches usually stop when the overused medicine is stopped. Ask your clinician before cutting back, because some medicines need a slow taper.
Can a primary care provider treat chronic migraine?
Yes, a primary care provider can evaluate chronic migraine and discuss preventive treatment options. Diagnosis is based on your history and physical and neurological exams, and imaging usually isn't needed unless another cause is suspected. At GENEVA in Alpharetta, your provider reviews your headache pattern and medicines, then recommends treatment at GENEVA or a referral to a headache specialist. The FDA advises asking for a migraine specialist referral if your treatment isn't working. A headache diary makes the first visit more useful.