Clinical recommendation	Evidence rating	References
Preventive therapy should be considered in patients having four or more headaches a month or at least eight headache days a month, significantly debilitating attacks despite appropriate acute management, difficulty tolerating or having a contraindication to acute therapy, medication overuse headache, patient preference, or the presence of certain migraine subtypes (i.e., hemiplegic migraine; migraine with brainstem aura; migrainous infarction; or frequent, persistent, or uncomfortable aura symptoms).	C	8
Divalproex (Depakote), topiramate (Topamax), metoprolol, propranolol, and timolol are effective for migraine prevention and should be offered as first-line treatment.	A	7–9, 11–18
Petasites has been established as effective and can be considered for migraine prevention.	B	29, 30
Behavioral treatments, such as relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive behavior therapy, are effective options for migraine prevention.	B	11, 32
Adding acupuncture to symptomatic treatment decreases the frequency of migraine headaches.	A	33