How to Stop Migraine Preventive Therapy
After achieving a period of stability with preventive therapy, clinicians should consider tapering or discontinuing treatment through shared decision-making with the patient. 1
When to Consider Stopping
The most recent guideline evidence suggests different timeframes based on migraine type:
- Episodic migraine: Consider tapering after 3-6 months of sustained improvement 2, 3
- Chronic migraine: Consider tapering after 6-12 months of sustained improvement 4, 2
The 2021 Nature Reviews Neurology guideline specifically states that pausing can be considered when treatment has been successful for 6-12 months, with the purpose of determining whether preventive treatment can be stopped entirely 4.
How to Taper
Gradual tapering is the recommended approach, though specific tapering schedules are not detailed in the guidelines. The principle mirrors the initiation strategy of "start low and go slow" - apply this in reverse when discontinuing 1.
Key Steps:
Ensure adequate trial period: The patient should have demonstrated sustained efficacy for the recommended duration (3-6 months for episodic, 6-12 months for chronic migraine)
Assess current status: Verify that migraine frequency, severity, and disability have meaningfully improved and remained stable
Patient education: Explain that migraine burden after withdrawal may:
- Return to pre-treatment levels
- Remain unchanged
- Fall somewhere in between 5
Monitor during taper: Have patients maintain headache diaries tracking attack frequency, severity, duration, and disability 1
Avoid acute medication overuse: Ensure patients are not overusing acute medications (limit to no more than twice weekly) during the taper period 1, 6
Special Considerations for Newer Therapies
For CGRP monoclonal antibodies, the current recommendation to discontinue after 6-12 months is based on expert opinion rather than robust scientific evidence 5. One proposed approach suggests stopping when migraine days decrease to ≤4 days per month, given the excellent tolerability profile 5.
What Happens After Stopping
Critical caveat: There is limited high-quality evidence on what happens after discontinuation. The guidelines acknowledge this gap 4, 5. Patients need ongoing dialogue about:
- The possibility of migraine recurrence
- When to reinitiate therapy
- Maintaining lifestyle modifications and trigger avoidance
- Appropriate use of acute medications
Ongoing Management
Therapy should be reevaluated on a regular basis through patient-clinician dialogue where patient expectations and goals are central to decisions about continuation or discontinuation 1. The 2025 ACP guideline notes there is uncertainty about whether and when to discontinue, emphasizing the need to reevaluate the balance of benefits, harms, and costs with each patient 7.
If migraines return to problematic levels after discontinuation, reinitiation of preventive therapy is appropriate, though persistence rates tend to be lower with subsequent treatment cycles 8.