Migraine: prophylactic treatment.

Prophylactic treatment constitutes an important aspect of migraine management and includes avoidance of trigger factors and life style advice followed by consideration of medications. The drugs of first choice are beta-blockers, flunarizine, topiramate, valproate and amitriptyline. Drugs of second choice with less efficacy and evidence are venlafaxine, gabapentin, naproxen, butterbur root, riboflavin and magnesium. Botulinum toxin type A has not yet been shown to be effective. The choice of prophylactic drugs would depend on efficacy, co-morbidity, side effects, availability and cost. Non-pharmacological treatments such as relaxation techniques, bio-feedback, cognitive behavioral therapy and acupuncture are supported by some evidence but require far more specialist time or technical devices. All the drugs used in migraine prophylaxis have been detected by serendipity. Drugs developed, in the future, on the basis of the current knowledge of pathophysiology will hopefully be more effective.