What are some strategies for migraine prevention?

Migraine Prevention Strategies

For effective migraine prevention, implement lifestyle modifications as first-line approach, followed by pharmacologic treatments such as beta-blockers, antiseizure medications, or tricyclic antidepressants for patients with frequent, debilitating headaches or inadequate response to acute treatments. 1, 2

Non-Pharmacological Prevention Strategies

Lifestyle Modifications

• Regular sleep schedule: Maintain consistent sleep and wake times, even on weekends 1, 2
• Regular meals: Avoid skipping meals to prevent hypoglycemia-triggered migraines 2
• Adequate hydration: Ensure sufficient daily water intake 1, 2
• Regular physical activity: Engage in moderate aerobic exercise regularly 2
• Stress management: Implement stress reduction techniques 2
• Trigger identification and avoidance: Use a headache diary to identify and avoid personal triggers 1

Behavioral Interventions

• Cognitive behavioral therapy: Helps manage stress and pain perception 1, 2
• Relaxation training: Progressive muscle relaxation and guided imagery 2
• Mindfulness-based treatment: Reduces stress and improves pain management 2
• Biofeedback: Particularly thermal biofeedback combined with relaxation training 2

Pharmacological Prevention Strategies

First-Line Medications

• Beta-blockers:

  • Propranolol (80-240 mg/day)
  • Timolol (20-30 mg/day)
  • Start at low dose and titrate gradually 1, 2

• Antiseizure medications:

  • Topiramate (100 mg/day)
  • Divalproex sodium (500-1500 mg/day)
  • Caution: Avoid in pregnancy due to teratogenic effects 2

• Tricyclic antidepressants:

  • Amitriptyline (30-150 mg/day)
  • Particularly useful for patients with comorbid depression or anxiety 2

Second-Line Medications

• Angiotensin-converting enzyme (ACE) inhibitors: Lisinopril 1
• Angiotensin receptor blockers (ARBs): Candesartan or telmisartan 1, 2
• Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine 1
• CGRP receptor antagonists: Erenumab for preventive treatment of migraine in adults 3, 4
• OnabotulinumtoxinA: FDA-approved for chronic migraine (≥15 headache days/month) 5, 6

Supplemental Therapies

• Magnesium: 400-600 mg daily 2
• Riboflavin (Vitamin B2): 400 mg daily 2, 7
• Coenzyme Q10: Consider as complementary treatment 4, 7

Treatment Approach Algorithm

1. Initial Assessment:

   • Evaluate headache frequency, severity, and disability
   • Consider pharmacologic prevention if:
     • ≥4 headache days per month
     • ≥8 headache days per month
     • Debilitating headaches despite acute treatment
     • Contraindications to acute treatments
     • Using acute treatments more frequently than recommended 1, 2

2. Start with Non-Pharmacological Approaches:

   • Implement lifestyle modifications for all patients
   • Add behavioral interventions as appropriate

3. Initiate Pharmacological Prevention:

   • Start with low dose and gradually increase
   • Allow 6-8 weeks at therapeutic dose to evaluate efficacy
   • Target goal: 50% reduction in attack frequency 2

4. Medication Selection Considerations:

   • Comorbidities (e.g., depression, hypertension)
   • Potential side effects
   • Cost (consider less costly recommended medications) 1
   • Pregnancy potential (avoid valproate and topiramate) 2

5. Treatment Monitoring:

   • Use headache diary to track frequency and response
   • Evaluate response after 2-3 months of treatment
   • If inadequate response, switch to another first-line agent 1, 2

Important Caveats and Pitfalls

• Medication overuse headache: Limit use of simple analgesics to <15 days/month and triptans to <10 days/month 2
• Pregnancy considerations: Avoid valproate and topiramate; discuss medication risks during pregnancy and lactation 1, 2
• Treatment expectations: Emphasize that improvement may occur gradually after initiation of preventive treatment 1
• Adherence importance: Stress that consistent medication use is crucial for effectiveness 1
• Discontinuation: Consider reevaluating the need for preventive treatment periodically, but no definitive guidelines exist on when to discontinue 1

By following this comprehensive approach to migraine prevention, most patients can achieve significant reduction in migraine frequency and severity, improving quality of life and preventing progression to chronic migraine.