From last resort to first consideration: Reframing migraine prevention

By Elizabeth PrattFact-checked by Barbara BekieszPublished November 3, 2025

Industry Buzz

Over time, patients can find that their migraine frequency increases, and 1-3% of patients with episodic migraine each year can proceed to having chronic migraine.

—Leon Moskatel, MD, migraine expert and professor of neurology at Stanford

Not only do we need to treat the individual attacks that you're having, but we need to also preventively treat the underlying disease process.

—Amaal Starling, MD, neurologist at Mayo Clinic

By the time some migraine patients reach preventive therapy, they have already endured years of pain. But experts say preventive options shouldn’t be viewed as a last ditch effort in managing migraine, and should be considered earlier.

“Starting preventative treatment earlier means that patients can gain better control of their migraine attacks sooner,” Leon Moskatel, MD, clinical assistant professor of adult neurology and an expert in migraine at Stanford, tells MDLinx.

“Over time, patients can find that their migraine frequency increases, and 1-3% of patients with episodic migraine each year can proceed to having chronic migraine, meaning migraine that happens on more than 15 days per month," he continues. "Early preventative treatment can help avert this chronification of their headache.”

The benefits of preventive therapies

As well as reducing the number of migraine attacks per month, experts say preventive options offer a number of benefits, including addressing the underlying disease pathology.

"There a lot of different treatment options that are available, but we need to initiate the conversation about, not only do we need to treat the individual attacks that you're having, but we need to also preventively treat the underlying disease process,” Amaal Starling, MD, a neurologist at Mayo Clinic, tells MDLinx.

Dr. Starling points out the significant benefits of preventive treatments: They can lessen the frequency and severity of attacks, improve response to rescue therapies, and lower the risk of disease progression.

It also is correlated to many quality of life measures, showing that people report lower amounts of disability and higher degrees of function when they're on preventive medication.

—Amaal Starling, MD, neurologist at Mayo Clinic

Resistance from patients

Some patients are resistant to preventive treatment options, and Dr. Starling argues this is when it is crucial physicians step in and have a conversation to reframe the perception of preventive treatments.

“When I'm talking to patients about initiating prevention, a lot of my patients will tell me, ‘I've got a really high pain threshold. I don't want to be on a daily medication. I don't want to be on a monthly injection. I can just deal with this. And I say… there is data that shows that individuals that have poorly managed migraine have a higher risk of developing chronic migraine the year after. So you have a higher risk of developing 15 or more headache days per month in the year after. And when people develop chronic migraine, it is harder to treat, there are higher risks of disability and lower function,” Dr. Starling says.

“And often, patients are like, ‘Oh, okay. Well, if you're telling me that if I don't initiate prevention now, that things can be worse; if you're framing this as a progressive disease, if I don't intervene now—then yes, I do want to go ahead and intervene now,'" she continues.

The American Headache Society recommends that preventive migraine treatment options be considered when a patient is having more than four migraine headache days per month. ^[] But there may be other justifications to try a preventive treatment.

“I have patients that may only have one or two migraine attacks per month, but they're pilots, or they're in a job, profession, or lifestyle in which they cannot even afford having one or two attacks. They would want to be on a preventive medication, even if their attacks are less frequent than four days per month,” Dr. Starling says.

SHARE THIS ARTICLE