What are the best strategies for headache and migraine prevention?

Best Strategies for Headache and Migraine Prevention

First-line pharmacologic treatments for migraine prevention include β-blockers (propranolol, timolol), antiseizure medications (valproate), tricyclic antidepressants (amitriptyline), and SNRIs (venlafaxine), which should be tried before newer, more expensive options like CGRP antagonists or monoclonal antibodies. 1, 2

Pharmacologic Prevention Strategies

When to Consider Preventive Therapy

• Initiate preventive therapy when patients experience two or more migraine attacks per month with disability lasting 3+ days per month 1, 2
• Consider prevention when patients use acute medications more than twice per week 1
• Evaluate for prevention when patients have contraindications to or failure of acute treatments 1
• Prevention is indicated for uncommon migraine conditions, including hemiplegic migraine or migraine with prolonged aura 1

First-Line Pharmacologic Options

• β-blockers: propranolol (80-240 mg/day) and timolol (20-30 mg/day) have established efficacy with Level A evidence 1, 3
• Antiseizure medications: divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) are effective first-line options 1, 2
• Tricyclic antidepressants: amitriptyline (30-150 mg/day) has consistent evidence supporting efficacy 1, 2
• SNRIs: venlafaxine is recommended as a first-line option by current guidelines 1, 2

Second-Line Pharmacologic Options

• Topiramate: suggested after failure of first-line agents due to higher frequency of adverse events 1
• CGRP antagonists-gepants (atogepant, rimegepant) or CGRP-mAbs (eptinezumab, erenumab, fremanezumab, galcanezumab): consider after failure of first-line agents due to substantially higher costs 1
• ACE inhibitors (lisinopril) or ARBs (candesartan, telmisartan): consider if recommended treatments are not tolerated or result in inadequate response 1

Non-Pharmacologic Prevention Strategies

Lifestyle Modifications

• Identify and manage modifiable triggers through headache diaries 1, 2, 4
• Maintain regular sleep patterns and adequate hydration 1, 2
• Engage in regular physical activity - aerobic exercise 2-3 times weekly for 30-60 minutes is effective for prevention 1
• Implement stress management techniques 2, 4

Behavioral Interventions

• Cognitive behavioral therapy has demonstrated efficacy for migraine prevention 1, 2, 5
• Biofeedback and relaxation training are effective non-pharmacologic approaches 1, 5
• Progressive muscle relaxation techniques can help reduce headache frequency 1, 5

Physical Therapy

• Physical therapy including thermal methods, trigger point massage, and mobilization techniques can be beneficial for migraine and tension-type headache management 1
• Progressive strength training, particularly upper-body exercises, can help prevent both migraine and tension-type headaches 1

Implementation Best Practices

Medication Administration

• Start preventive medications at a low dose and gradually titrate up to minimize side effects 1, 2
• Allow adequate trial periods (2-3 months) before determining effectiveness 1
• Monitor for adverse effects and adjust accordingly 1

Patient Education and Monitoring

• Use headache diaries to track frequency, severity, duration, and response to treatment 1, 2
• Educate patients that migraine is a neurological disorder with a biological basis 1
• Set realistic expectations that improvement may occur gradually after initiation of preventive treatment 1

Common Pitfalls to Avoid

• Discontinuing treatment too early before therapeutic effect is achieved (typically needs 2-3 months) 1, 2
• Not starting at low doses and gradually titrating up, leading to unnecessary side effects 1, 2
• Failing to address medication overuse, which can lead to rebound headaches 2, 6
• Overlooking comorbid conditions that may influence treatment selection 1, 2

Special Populations

• In women of childbearing potential, discuss potential teratogenic effects, particularly with valproate and topiramate 1, 2
• Consider pregnancy and breastfeeding status when selecting preventive medications 1

By following these evidence-based strategies and selecting appropriate preventive treatments based on individual factors, migraine frequency and severity can be significantly reduced, improving quality of life and reducing disability.