THE HALF MOST PEOPLE ARE NEVER GIVEN
Headache prevention comes in four families. They are oral daily preventives, CGRP-targeted treatments, procedures such as botulinum toxin and nerve blocks, and a non-drug half. That half is sleep timing, regular meals, exercise and behavioral work. Roughly halving headache days is a normal, good outcome.
Prevention is a category, not a drug. It becomes worth discussing at around four headache days a month. A great many people have been moved up through stronger acute treatments for years, and nobody ever raised it.
What are the main types of preventive headache treatment?
ORAL DAILY PREVENTIVES
- Several well-known classes, mostly borrowed from cardiology, neurology and psychiatry.
- Chosen as much for your other conditions as for the headache. One drug may help blood pressure or sleep. Another may not suit low mood or weight concerns.
- Need a proper dose for long enough before being called a failure. That is usually 8 to 12 weeks.
CGRP-TARGETED TREATMENTS
- Designed for migraine specifically rather than repurposed.
- Monthly or quarterly injection, or a daily oral option.
- Generally easier to tolerate than the older oral classes. Usually require documented failure of two or more of them first. That is an access rule, not a clinical one.
PROCEDURAL AND INTERVENTIONAL
- Botulinum toxin for chronic migraine at 15 or more days a month.
- Nerve blocks where the examination shows an occipital or cervical component.
- Useful when pills are not tolerated, or to hold a floor while an overuse pattern is unwound.
THE NON-PHARMACOLOGICAL HALF
- Sleep timing, regular meals, graded aerobic exercise and behavioral work have real, measured effect sizes. They are not a consolation prize.
- Done in-house here, not referred out, because a plan that ignores your actual week does not survive one.
Why does a migraine preventive seem not to work?
First, the trial was too short or too weak. It was stopped at two weeks for a side effect that would have settled. Or the dose was never raised to one that works. That is an incomplete trial, not a failed one, and it wrongly closes off a whole class. Bring the dose and how long you took it, not just the name.
Second, judging it on top of medication overuse. Nothing looks effective while an overuse layer is running. That is why the order is: count, unwind, then judge. How that unwinding works.
How well should a preventive treatment work?
Roughly halving headache days is a normal, good outcome. Zero is not the target. Promising it is how people end up let down by a treatment that worked. Set the goal before starting, in days per month, and check against it.
Frequently asked questions
When should I start a preventive?
Around four headache days a month is where most guidance starts to weigh it. Sooner if attacks are severe or disabling. See the frequency ladder.
How long until I know?
Eight to twelve weeks at a proper dose for pills. Two cycles for botulinum toxin. Judging earlier is the most common reason a workable option gets thrown out.
Do I have to take something every day?
No. Procedural options and the behavioral half are real preventives. For a predictable trigger like a menstrual pattern, timed treatment is possible. See the hormonal page.
What if I have tried everything?
Bring the list with doses and how long you took each. In practice a real share of “everything” turns out to be incomplete trials. That changes what is still available.
See “I have tried everything” is usually four things, and three are fixable.
What can I take every day to prevent migraines?
Oral daily preventives come from several well-known classes, mostly borrowed from cardiology, neurology and psychiatry. The choice depends as much on your other conditions as on the headache. One drug may also help blood pressure or sleep. Another may not suit low mood or weight concerns. There is also a daily oral CGRP-targeted option designed for migraine specifically.
What are CGRP treatments for migraine?
CGRP-targeted treatments were designed for migraine specifically, not borrowed from another field. They come as a monthly or quarterly injection or as a daily tablet. They are generally easier to tolerate than the older oral classes. Access usually requires documented failure of two or more of the older preventives first. That is an access rule, not a clinical one.
Can you prevent migraines without medication?
Yes. Sleep timing, regular meals, graded aerobic exercise and behavioral work have real, measured effect sizes. They are a true half of prevention, not a consolation prize. We deliver them in-house instead of referring you out, because a plan that ignores how your actual week runs does not survive one.
Can Botox or nerve blocks prevent headaches?
They can. Botulinum toxin is used for chronic migraine at 15 or more headache days a month. Nerve blocks are used when the exam shows an occipital or neck component. Both earn their place when pills are not tolerated. They also help hold a floor while a medication-overuse pattern is unwound.
Where to go from here
Four nutrients have real prevention evidence, and all four act on how a neuron makes energy.
Bring the doses and the durations, not just the names
It is the single detail that decides whether a class is genuinely exhausted or barely tried.
12174 Natural Bridge Rd, Suite 304
St. Louis, MO 63044
Next to DePaul Hospital, off the I‑270 and I‑70 junction, west of the airport.
Sources
- Diener HC et al. Drugs for Migraine Prophylaxis. Deutsches Arzteblatt international, 2026. PubMed 41572863
- Haghdoost F et al. Evaluating the efficacy of CGRP mAbs and gepants for the preventive treatment of migraine: A systematic review and network meta-analysis of phase 3 randomised controlled trials. Cephalalgia : an international journal of headache, 2023. PubMed 36855951
- von Luckner A et al. Magnesium in Migraine Prophylaxis-Is There an Evidence-Based Rationale? A Systematic Review. Headache, 2018. PubMed 29131326
- Chen YS et al. Effect of Vitamin B2 supplementation on migraine prophylaxis: a systematic review and meta-analysis. Nutritional neuroscience, 2022. PubMed 33779525