What are the risk factors and management options for migraines?

Risk Factors for Migraines

The key risk factors for migraines include female sex, poor sleep quality, stress, physical inactivity, obesity, menstruation, and comorbid conditions such as depression and anxiety. 1 While predisposing and trigger factors are often overemphasized in migraine management, understanding these risk factors is essential for effective prevention and treatment.

Primary Risk Factors

Demographic and Genetic Factors

• Female sex: Women are significantly more affected than men, with approximately 25% of women experiencing migraines compared to 9% of men 1
• Genetic predisposition: Migraine has a significant hereditary component with over 100 genetic loci linked to migraine susceptibility 2
• Age: Most common in young adults, with peak prevalence between ages 30-39

Physiological and Hormonal Factors

• Menstruation: A critical trigger for many women, with some experiencing exclusively or frequently menstruation-related migraines 1
• Hormonal changes: Fluctuations in estrogen levels can trigger migraines in susceptible individuals
• Pregnancy and menopause: Can affect migraine patterns (improvement or worsening)

Lifestyle and Environmental Factors

• Poor sleep quality: Disrupted or insufficient sleep increases migraine susceptibility 1
• Physical inactivity: Inadequate physical fitness is a predisposing factor 1
• Stress: Both acute and chronic stress can trigger migraine attacks 2
• Dietary factors: Certain foods and fasting can precipitate attacks in susceptible individuals
• Weather patterns: Changes in barometric pressure, temperature, and humidity 2
• Sensory stimuli: Bright lights, strong smells, and loud noises 2

Comorbid Conditions as Risk Factors

• Depression and anxiety: Strongly associated with migraine, especially chronic migraine 1
• Sleep disorders: Insomnia and other sleep disturbances increase risk 1
• Obesity: Important risk factor for transformation from episodic to chronic migraine 1
• Other chronic pain conditions: Neck and lower back pain often coexist with migraine 1

Risk Factors for Progression to Chronic Migraine

Chronic migraine (≥15 headache days per month for at least 3 months, with migraine features on ≥8 days) represents a more severe disease state with greater disability. Risk factors for progression include:

• High frequency of episodic migraine: More frequent attacks increase risk of chronification 3
• Medication overuse: Regular overuse of acute headache medications (≥10-15 days/month) 1
• Female sex: Women are more likely to develop chronic migraine 1
• Obesity: Significantly increases risk of transformation 1
• Comorbid conditions: Depression, anxiety, and other pain disorders 1
• Inadequate treatment: Ineffective acute or preventive therapy 3

Management Considerations Based on Risk Factors

Lifestyle Modifications

• Sleep hygiene: Establish regular sleep patterns
• Stress management: Relaxation techniques, cognitive behavioral therapy
• Physical activity: Regular exercise appropriate to the patient's condition
• Weight management: For patients with obesity
• Trigger avoidance: Identify and avoid personal triggers when possible, without excessive lifestyle restrictions that could impair quality of life 1

Pharmacological Management

Acute Treatment

1. First-line for mild to moderate attacks: NSAIDs (ibuprofen, diclofenac potassium, acetylsalicylic acid) 1, 4
2. First-line for moderate to severe attacks: Triptans (sumatriptan, etc.) 1, 4
   • Most effective when taken early in an attack while pain is still mild 1
   • Contraindicated in patients with coronary artery disease, uncontrolled hypertension, or stroke history 5
3. Second/third-line options: Antiemetics, dihydroergotamine, combination analgesics 4

Preventive Treatment

For patients with frequent migraines or risk factors for chronification:

1. First-line preventives:

   • Beta-blockers (propranolol, metoprolol)
   • Anticonvulsants (topiramate)
   • Angiotensin II-receptor blockers (candesartan) 1

2. Second-line preventives:

   • Amitriptyline (especially for patients with depression or sleep disturbances)
   • Flunarizine
   • Sodium valproate (contraindicated in women of childbearing potential) 1

3. Third-line preventives:

   • OnabotulinumtoxinA (for chronic migraine) 1, 6
   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1, 7

Special Considerations for Hormonal Risk Factors

• For menstrual migraines: Consider perimenstrual preventive treatment with long-acting NSAIDs or triptans for 5 days starting 2 days before expected menstruation 1
• For women with pure menstrual migraine without aura: Continuous use of combined hormonal contraceptives may be beneficial 1
• Important caveat: Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1

Monitoring and Follow-up

• Regular follow-up is essential to evaluate treatment response and adjust therapy as needed
• Use headache calendars to track frequency, severity, and medication use 1
• Monitor for medication overuse, which can lead to medication overuse headache (MOH) 1
• Assess for development or worsening of comorbid conditions

Understanding and addressing these risk factors through appropriate lifestyle modifications and pharmacological interventions can significantly improve outcomes and quality of life for patients with migraine.