Migraine prevention can be instrumental in the effective management of the migraine patient but remains underused in treatment of this common, chronic, and often debilitating condition. The development of methysergide as the first migraine preventive agent not only laid the groundwork for our current thinking about migraine prevention, but also created a paradigm shift away from migraine as a psychological issue and toward migraine as a legitimate medical condition. This short review is intended to help the reader select patients appropriate for prevention and to initiate, monitor, and adjust preventive treatment. Goals in discussing preventive management are to facilitate provider familiarity with and confidence in this therapy leading to improved clinical outcomes and to a reduced burden of headache-related disability. Optimal therapeutic success is best achieved in the setting of a strong therapeutic alliance. Medication options for prevention are reviewed. Continued educational efforts directed at both patient and provider may be required to improve treatment utilization and reduce headache impact.