Part of the Access Doctor migraine treatment guide. Conditions overview: migraine & headache UK.
Migraine Prevention UK: Propranolol, Topiramate & How to Reduce Attacks
A clinically reviewed guide to preventive migraine treatment — who should consider it, propranolol as first-line, topiramate, amitriptyline, and specialist options including CGRP inhibitors.
▶ Migraine prevention at a glance
NICE recommends preventive migraine treatment for 4+ migraine days per month. First-line: propranolol (40–160mg daily, reduces frequency 40–50%). Alternatives: topiramate (avoid in pregnancy — teratogenic) and amitriptyline. Specialist options include CGRP inhibitors and botulinum toxin for chronic migraine. GPhC pharmacy #9011198.
4+
Migraine days/month — NICE threshold for prevention
40–50%
Reduction in attack frequency with propranolol
40–160mg
Propranolol daily dose range
8–12wk
Time to assess full effect of preventive treatment
Who Should Consider Prevention?
NICE recommends considering preventive treatment if any of the following apply:
- Migraines occur on 4 or more days per month
- Attacks significantly impair daily functioning or quality of life
- Acute treatments are poorly tolerated, contraindicated, or ineffective
- Medication overuse headache has developed (acute medication used >10–15 days/month)
- Migraine with unusual features (e.g., prolonged aura)
Prevention does not replace acute treatment — it reduces how often you need it. Most people on preventive therapy still carry acute medication for breakthrough attacks.
Propranolol (First-Line)
Propranolol is a beta-blocker and the most widely prescribed first-line preventive treatment for migraine in the UK. It reduces migraine frequency by 40–50% in clinical trials.
| Detail | Information |
|---|---|
| Dose | 40–160mg daily (in divided doses or modified-release once daily) |
| Time to effect | 4–8 weeks; full assessment at 8–12 weeks |
| Common side effects | Fatigue, cold extremities, sleep disturbance, bradycardia |
| Contraindications | Asthma (absolute), uncontrolled heart failure, second/third degree AV block, Raynaud’s phenomenon (relative) |
| Interaction | Rizatriptan: use 5mg not 10mg with propranolol; sumatriptan standard dose is acceptable |
Asthma contraindication: Propranolol is absolutely contraindicated in asthma. If you have asthma, discuss alternative preventives (topiramate, amitriptyline) with your prescriber.
Topiramate
Topiramate is an anticonvulsant with strong evidence for migraine prevention, comparable in efficacy to propranolol. It is an alternative for patients in whom propranolol is contraindicated or poorly tolerated.
- Dose: 25mg daily increasing to 50–100mg daily over 4–8 weeks
- Common side effects: cognitive slowing (“brain fog”), paraesthesia, weight loss, kidney stones
- Teratogenic — avoid in pregnancy and in women of reproductive age without highly effective contraception
- Not recommended in women of childbearing potential without a FSRH-approved contraceptive method in place
Amitriptyline
Amitriptyline (a tricyclic antidepressant) is used off-label for migraine prevention, particularly when migraine co-exists with tension-type headache or sleep disturbance. Typical preventive dose is 10–50mg at night, much lower than the antidepressant dose.
When Prevention Is Not Enough: Specialist Treatments
If three or more preventive medicines have been tried without adequate benefit — or if migraine has become chronic (15+ headache days/month) — specialist-only treatments are available on the NHS:
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) — monthly or quarterly injections; via neurology following failure of conventional preventives
- Botulinum toxin A (Botox) — NICE TA260; for confirmed chronic migraine; via specialist headache service
Full detail on these specialist treatments — eligibility criteria, procedure, efficacy data and NHS access: Chronic migraine treatment guide →
Assess Your Migraines Online
If you have 4+ migraine days per month, preventive treatment may significantly reduce attacks. Our GPhC-registered prescribers can assess online. GPhC pharmacy #9011198.
Assess My Migraines →Frequently Asked Questions
When should I start migraine prevention?
Consider preventive treatment if you have 4 or more migraine days per month, if attacks significantly impair your quality of life, if acute treatments are not working well, or if you are using acute medication more than 10–15 days per month.
How long does propranolol take to work for migraine?
Full effect takes 8–12 weeks. Some reduction in frequency may be noticeable after 4–8 weeks. Propranolol must be taken consistently every day — it does not provide immediate relief for individual attacks.
Can I take propranolol if I have asthma?
No. Propranolol is absolutely contraindicated in asthma because it can cause bronchoconstriction. If you have asthma, topiramate or amitriptyline are alternatives to discuss with your prescriber.
Is topiramate safe for women?
Topiramate is teratogenic — it can cause serious birth defects. It should not be used in pregnancy or by women of reproductive age without highly effective contraception. Discuss the full risk-benefit balance with your prescriber.
Can I still take triptans while on preventive medication?
Yes. Preventive treatment reduces how often attacks occur but does not prevent them entirely. You can and should continue to carry acute medication (triptans, naproxen) for breakthrough attacks.
References
- NICE. Headaches in over 12s: diagnosis and management. CG150.
- BASH. Guidelines for the diagnosis and management of migraine. 4th ed. 2010.
- NHS. Propranolol. nhs.uk/medicines/propranolol
Medical disclaimer: This article is for informational purposes only. Prescription migraine treatments require a clinical consultation. Always consult a qualified healthcare professional. In a medical emergency, call 999.