Preventative Measures for Headaches and Migraines
For effective prevention of headaches and migraines, implement a combination of lifestyle modifications, behavioral interventions, and pharmacologic treatments tailored to headache frequency and severity. 1, 2
When to Consider Preventive Treatment
Preventive treatment should be considered when:
- Migraines occur ≥2 days per month with significant impact despite optimized acute treatment 2
- Patient experiences severe debilitating headaches despite adequate acute treatment 1
- Patient is unable to tolerate or has contraindications to acute treatment 1
- Patient is using acute treatments more often than recommended (risk of medication overuse headache) 1
First-Line Preventive Strategies
Lifestyle Modifications
- Regular sleep schedule - maintain consistent sleep and wake times 2
- Consistent meal timing - avoid skipping meals to prevent hypoglycemia-triggered headaches 2
- Adequate hydration - drink sufficient water throughout the day 2
- Regular exercise program - engage in moderate to intense aerobic exercise 2
- Stress management - practice yoga, cognitive-behavioral therapy, or mindfulness 2
- Caffeine management - limit intake to prevent headache exacerbation 2
- Weight management - weight loss for overweight/obese patients 2
Dietary Trigger Identification
- Use food diaries to identify potential triggers 3
- Common dietary triggers to monitor:
- Phenylethylamine (found in chocolate, aged cheese)
- Tyramine (in aged cheeses, cured meats)
- Aspartame (artificial sweetener)
- Monosodium glutamate (MSG)
- Nitrates and nitrites (in processed meats)
- Alcohol
- Caffeine 3
Pharmacologic Prevention
First-Line Medications
Based on the most recent guidelines, consider these medications in order of preference:
Beta-blockers:
Anticonvulsants:
Tricyclic antidepressants:
Second-Line Options
If first-line treatments are not tolerated or ineffective:
- ACE inhibitors (lisinopril)
- ARBs (candesartan or telmisartan)
- SSRIs (fluoxetine)
- SNRIs (venlafaxine) 1, 2
Newer Agents
CGRP antagonists and monoclonal antibodies:
- Atogepant, rimegepant (CGRP antagonists)
- Eptinezumab, erenumab, fremanezumab, galcanezumab (CGRP monoclonal antibodies) 2
Supplement Options
Evidence supports the following supplements for migraine prevention (in decreasing order of preference):
- Magnesium
- Petasites hybridus (butterbur)
- Feverfew
- Coenzyme Q10
- Riboflavin (vitamin B2)
- Alpha lipoic acid 3, 4
Implementation Tips
- Start low, go slow - Begin pharmacologic treatment at a low dose and gradually increase until desired outcomes are achieved 1
- Allow adequate trial period - Give preventive medications 2-3 months to show efficacy 1, 2
- Use headache diary - Track frequency, severity, triggers, and treatment response 1
- Consider cost factors - When treatments have similar benefits, consider cost in treatment selection 1
- Regular reassessment - Periodically reevaluate the need for continued preventive treatment 1
Common Pitfalls to Avoid
Inadequate trial duration - Many patients discontinue preventive medications too early before they reach full efficacy (typically 3-4 months needed) 2
Medication overuse - Using simple analgesics >15 days/month or triptans/combination analgesics >10 days/month can lead to medication overuse headache 2
Ignoring comorbidities - Failing to address sleep disorders, anxiety, depression, or other conditions that may exacerbate migraines 5
Overlooking lifestyle factors - Relying solely on medications without addressing fundamental lifestyle triggers 5
Stigmatizing patients - Avoid blaming patients for their migraines when lifestyle modifications don't completely resolve symptoms 6
By implementing these preventive measures systematically and allowing adequate time for response, many patients can achieve significant reduction in headache frequency and severity, improving their quality of life.