When should migraine prevention medication be started?

When to Start Migraine Prevention Medication

Migraine prevention medication should be started when patients experience two or more attacks per month that produce disability, contraindication to or failure of acute treatments, use of abortive medication more than twice per week, or presence of uncommon migraine conditions. 1, 2

Primary Indications for Preventive Therapy

The American Academy of Neurology and American Headache Society recommend initiating preventive therapy in the following situations:

• Frequency-based criteria:

  • Two or more migraine attacks per month that produce disability lasting 3 or more days per month 1
  • Patients who remain adversely affected on at least 2 days per month despite optimized acute therapy 1
  • Four or more headaches a month 3
  • Eight or more headache days a month 3

• Medication use patterns:

  • Contraindication to or failure of acute treatments 1, 2
  • Use of abortive medication more than twice per week 1
  • Risk of medication overuse headache 2, 3
  • Excessive intake of acute medication (more than twice a week) 4

• Impact on quality of life:

  • Debilitating headaches 3
  • Significant disability despite acute treatment 2
  • Patients who consider their quality of life reduced between attacks 4

• Special migraine types:

  • Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, or migrainous infarction) 1

Important Considerations When Starting Prevention

• Efficacy timeline: Clinical benefit may take 2-3 months to manifest, so adequate trial periods are essential 1
• Evaluation period: Efficacy should be assessed after 2-3 months for oral preventives, 3-6 months for CGRP monoclonal antibodies, and 6-9 months for onabotulinumtoxinA 1
• Medication selection: First-line options include beta blockers (propranolol, metoprolol, timolol), topiramate, candesartan, amitriptyline, and divalproex sodium 1, 2
• Monitoring: Use headache diaries to track attack frequency, severity, duration, resulting disability, response to treatment, and medication side effects 1, 2

Potential Pitfalls to Avoid

• Medication overuse: Avoid overuse of acute medications during preventive treatment as this can interfere with effectiveness 1, 5
• Premature discontinuation: Do not abandon treatment in early stages due to apparent inefficacy 1
• Inadequate dosing: Gradually increase doses to reach recommended therapeutic levels while monitoring tolerance 4
• Failure to address comorbidities: Managing comorbid conditions is crucial for improving overall outcomes 2, 6

Treatment Duration and Reassessment

• After a period of stability (6-12 months of successful treatment), consider tapering or discontinuing treatment 1
• If one preventive treatment fails, try another drug class, as failure of one does not predict failure of others 1
• Regularly reassess diagnosis, treatment strategy, and adherence if outcomes are suboptimal 2

By following these guidelines, clinicians can appropriately identify patients who would benefit from migraine prevention medication, potentially reducing the frequency and severity of attacks, preventing progression to chronic migraine, and improving overall quality of life.