Tapering and Discontinuing Preventive Migraine Treatments
If you’ve found a preventive migraine treatment that gives you great results with mild or no side effects, you might feel like you’ve won the lottery! Finally, you’re having far fewer migraine attacks than you used to, and the ones you have are likely easier to manage with acute medications.
But how long do you have to stay on preventive migraine treatments? How do you know when it’s time to stop? And how do you stop using them – a little at a time or all at once?
Although there’s no single guideline that applies to everyone or every treatment, emerging evidence can help you and your healthcare provider decide when and how to start, stop, or restart migraine prevention.
Evolving Ideas About “Successful” Migraine Prevention
Guidance for discontinuing successful preventive treatments depends on the definition of “success” in migraine prevention—an idea that’s evolving along with the science of migraine.
In clinical trials and clinical practice, the traditional benchmark for “success” in migraine prevention has been a 50% or greater reduction in monthly migraine or headache days, or at least a similar reduction in moderate-to-severe headache days.1 Other important considerations for success with preventive treatment are an improved response to acute treatment and a significant decrease in attack duration, migraine disability, and/or psychological distress.1
The approval of onabotulinumtoxinA (Botox) for the prevention of chronic migraine in 2010 gave clinicians a new option. Although the treatment has a low side effect profile, real-world evidence suggests that fewer than half of people who try it get a reduction in monthly migraine days (MMD) of 50% or more.2
Then a new generation of treatments was introduced to target calcitonin gene-related peptide (CGRP), a neuropeptide involved in migraine process. Since 2018, six treatments have been approved in the U.S. and elsewhere for migraine prevention. Four CGRP monoclonal antibodies (or mAbs) and one gepant were approved for the prevention of episodic and chronic migraine. Another gepant is approved for the prevention of episodic migraine.
A 2025 position statement from the International Headache Society urges researchers, healthcare providers, and individuals with migraine to strive for the “highest possible outcomes” in migraine prevention.3 Ideally, this would be zero migraine or headache days per month, but achieving “optimal control” can also be considered when an individual has fewer than 4 moderate to severe headache days. While recognizing the importance of the traditional benchmarks for clinical trials, statement authors argue that recent advances in science and clinical practice demonstrate that “meaningful reductions, and even the elimination of disability as a result of migraine, are now a real possibility for some individuals with migraine.”3
Is It Time to Say Goodbye to Your Preventive?
With so much information, how do you and your healthcare provider decide if it’s time for you to say goodbye to the preventive treatment that is giving you great results?
Goalposts for success
Guidelines from the International Headache Society suggest using oral medications for at least 6 months and injections or other non-oral treatments for at least 12-18 months before considering discontinuation.3 After that period, a clinician may consider tapering you off treatment once your migraine attacks are reduced to fewer than four days per month for at least three months in a row, or when you feel satisfied with your level of improvement.3
Clues about discontinuation from other studies
In addition to the new IHS guidelines, details from several unrelated clinical studies and analyses suggest that other factors may offer clues about whether it’s a good time (or not) to try discontinuing your preventive treatments.
Here are some factors to discuss with your healthcare provider to help decide if it’s time to discontinue or stay on your preventive treatment:
Sensory sensitivity: Symptoms like heightened sensitivity to light or sound are common during and between migraine attacks. If these sensitivities are still present, it may be a sign that preventive treatment is still needed. The same is true for allodynia, or heightened sensitivity to tactile stimulation that normally isn’t painful (the famous “even my hair hurts” symptom). Persistent allodynia can be associated with medication overuse headache and treatment-resistant forms of migraine. If light, sound, or touch sensitivity continues despite preventive therapy, it may indicate that staying on treatment longer could help reduce the risk of worsening symptoms.
How long you’ve had migraine: Individuals with earlier onset and longer duration of migraine disease may need extended courses of successful preventive treatment for the best outcomes and reduced risk of relapse. If you’ve had migraine attacks for decades before finding effective preventive treatment, you might need a longer course of therapy than a friend who started successful prevention soon after their migraine disease began.
Severity: The more severe your condition was before finding your best preventive treatment, the longer you may need to stay on it to prevent relapse after stopping. For example, if you had chronic migraine (15+ headache days per month plus 8 days with migraine symptoms), you might benefit from a longer duration of preventive treatment than someone with episodic migraine (<15 headache days per month).
Medication overuse headache: Medication overuse headache (MOH) develops from frequent use of medications for headache, migraine, or other pain conditions. These headaches occur on more than 14 days per month for at least 3 months and often appear daily or upon waking. If you and your healthcare provider suspect that you have medication overuse headache in addition to migraine, a longer duration of preventive treatment may be a good idea. MOH is believed to change the way your brain responds to migraine attacks and other stimuli. A longer course of successful preventive treatment gives your brain more time to reverse those changes and “reset” to a less reactive state.
Lifecycle: Migraine disease can change in severity throughout a person’s life. People with migraine often experience an increase in migraine frequency and severity during perimenopause, the period of hormonal fluctuations leading up to menopause. If you’re in or near perimenopause, it might be a good time to stay on a preventive treatment that works and have additional strategies (like neuromodulation devices, nutritional supplements, lifestyle changes) ready to add to your prevention plan.
On the other hand, if you have already finished menopause, you’re likely to have a gradual improvement in migraine regardless of preventive treatments, especially if you have episodic migraine. This might be a good time to try discontinuing your preventive treatment.
There is one serious exception to the conventional wisdom about menopause improving migraine. If your healthcare team recommends surgical removal of your ovaries for another medical reason, please work with your healthcare team on a vigorous migraine prevention plan. The sudden hormonal shift of surgical menopause has been associated with worsening migraine symptoms.4
Your personal migraine history: An interesting 2024 study followed 360 individuals with migraine in Spain who had good therapeutic responses to CGRP monoclonal antibodies (mAbs) for 12-18 months.5 These individuals stopped using CGRP mAbs (median treatment break: 4 months) and then restarted them when their symptoms returned.5 Most individuals had a therapeutic response when they resumed using CGRP mAbs, but after three months of treatment following the break, only a third of them reached the same level of therapeutic response they had on the first round.5
The interesting details are in the analysis researchers performed to determine factors associated with poorer second-round response:5
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People with an earlier onset of migraine disease
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People with chronic migraine
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People who had a history of medication overuse headache (MOH) with triptans and NSAIDS
The analysis suggests that people who have the most difficult-to-treat forms of migraine might benefit from longer periods of preventive treatments.5
Taper or Cold Turkey? How to Discontinue Migraine Prevention
If you and your healthcare provider agree that it’s time for you to discontinue your preventive treatment, it’s important to know which treatments require careful tapering and which do not.
Traditional oral medications
The following medications require tapering before they can be discontinued. Do not stop taking them suddenly!
- Tricyclic antidepressants (like amitriptyline or nortriptyline)
- Beta blockers (like propranolol)
- Calcium channel blockers (like verapamil)
- Anti-seizure medications (like topiramate or sodium valproate)
- Selective serotonin-norepinephrine reuptake inhibitors (SNRIs like venlafaxine)
These medications all have well-established guidelines for safe tapering. Follow your provider’s instructions for tapering slowly in small steps (this may involve a 25% reduction in dose at scheduled intervals). Some people may experience uncomfortable side effects during a taper, so work with your healthcare provider to fine-tune the process—you may feel better if you take “baby steps” smaller than the recommended guidelines or proceed more slowly.
OnabotulinumtoxinA
Your healthcare provider can schedule a longer interval between injections of onabotulinumtoxinA to gauge your reaction. If you typically receive injections every three months, consider stretching the interval between injections to four months. If your symptoms remain stable on that schedule, gradually extend the intervals until you and your healthcare provider agree that you can stay on an extended schedule or discontinue injections altogether. Reevaluate in 4-5 months after stopping to ensure you have not reverted to chronic migraine.6
CGRP Monoclonal Antibodies
Because CGRP mAbs have long half-lives (approximately 30 days, depending on the specific medication), it is safe to stop using these treatments without a taper.
Gepants
We could not find clear guidance on discontinuing the preventive use of gepants. Given their relatively low risk of side effects and short half-lives, they appear to present little risk of discontinuation syndrome or dangerous side effects if you discontinue them without a taper, but that’s a subject you should discuss with your healthcare provider.
Headache After Discontinuation of Migraine Preventive
What if headache or migraine frequency increases during the time you are tapering off your preventive treatment?
Dr. Jennifer Robblee, an Association of Migraine Disorders executive board member, explains, “I usually counsel patients to let me know if they have worsening headache or other symptoms during the wean. I have them go back up to the previous dose and stay there for at least another 1-2 weeks. Then we discuss whether they want to hold steady at that dose for now or re-try to wean off the medication. The worsening could be a transient increase in headache, or it may mean the medication was simply keeping migraine under control.”
For individuals who experience an increase in headache days after completing the weaning process, the International Headache Society recommends waiting at least one month before restarting treatment, provided they meet the criteria for preventive treatment (i.e., 4 or more headache days per month).3
It’s essential to maintain close contact with your healthcare provider throughout this process and keep them informed of any changes in your symptoms.
During and After Discontinuation
Always consult your healthcare provider before tapering or discontinuing any treatment. If you do stop a preventive treatment, keep tracking your migraine attacks in a diary or app. Also, keep track of how often you are using your acute treatment (ex., triptan, gepant, dihydroergotamine, or over-the-counter medication). This will help you see whether changes in your symptoms, frequency, or severity are minor and settling on their own, or if they suggest you may need to restart preventive treatment.
Consider frequent check-ins with your healthcare provider during the first three months of discontinuing any preventive medication. Together, you can monitor your progress, adjust your plan along the way, and restart prevention quickly if needed.
If you need to go back on your preventive therapy, don’t feel guilty about restarting. Some people with migraine will be able to stop using preventives and have great results; others may need preventive therapy for a longer duration. Migraine isn’t a one-size-fits-all disease, and neither is your treatment. You and your healthcare provider can work together to make the decisions that are best for you.
References
- https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14153
- https://link.springer.com/article/10.1186/1129-2377-15-54
- https://journals.sagepub.com/doi/full/10.1177/03331024251320608
- https://americanmigrainefoundation.org/resource-library/hysterectomy-and-migraine-what-to-expect/
- https://europepmc.org/article/MED/38270379
- https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-018-0921-8
Author
Lisa had migraine attacks for most of her adult life before being diagnosed with migraine disease. A communications strategist, writer, and former radio announcer, she lives in the Boston area, where she advocates for her fellow migraine patients every chance she gets.
