What is the minimum headache or migraine days per month that you would consider starting preventative migraine therapy?

I would start thinking about preventive therapy when headaches get to be about 4-6 times a month. This is the number at which there is evidence that headaches will start to progress to chronic, which is considered to be 15 times a month.

If a patient is increasing their abortive use or each migraine attack is lasting over a day and is very severe, that is also a reason to start thinking about starting a preventive, especially if there is an aura that lasts for some time.

4 migraines per month should start the discussion of preventive therapy. It may be considered in less than that if the patient has very disabling or prolonged migraines, where they are missing work or school, and it is disruptive.

Rule of thumb: more than 2 days a week, based on preventing analgesic overuse headaches. This presupposes that abortives work well. If the headaches are usually prolonged or resistant to episodic treatment, resulting in functional impairment, a lower threshold for preventive management is warranted. Conversely, if most of the headaches are reliably clustered around a short period of time and abortive-responsive, additional prophylaxis may not be necessary.