What are the risk factors and management strategies for migraines?

Migraine Risk Factors

Migraine risk factors include both modifiable and non-modifiable elements, with obesity, poor sleep quality, stress, medication overuse, and sedentary lifestyle being the most critical modifiable factors that directly increase the risk of transformation from episodic to chronic migraine.

Non-Modifiable Risk Factors

• Female sex and hormonal fluctuations are major risk factors, with menstruation being a particularly important trigger for many women who experience exclusively or frequently menstruation-related attacks 1
• Genetic predisposition plays a significant role, with particular genetic backgrounds favoring the appearance of chronicity and medication overuse 2
• Age-related patterns show that migraine prevalence increases during adolescence, though it often remits with older age 1
• Family history of migraine substantially increases individual risk 1

Critical Modifiable Risk Factors

Obesity and Metabolic Factors

• Obesity is the single most critical modifiable risk factor for transformation from episodic to chronic migraine and must be aggressively addressed 3, 4
• Maintaining an ideal body mass index (BMI) could prevent approximately 5.65% of migraine cases 5
• Weight loss is particularly crucial in obese patients, making topiramate an especially beneficial preventive choice due to its weight loss effect 4

Sleep Disturbances

• Poor sleep quality and irregular sleep patterns are major predisposing factors that increase susceptibility to migraine attacks 1, 6
• Maintaining adequate sleep duration and consistent sleep patterns could prevent approximately 10.16% and 16.39% of migraine cases, respectively 5
• Regular sleep schedules should be emphasized as a core intervention 4, 7

Physical Activity and Sedentary Behavior

• Sedentary lifestyle significantly increases migraine risk, with reduction in sedentary time potentially preventing 6.57% of cases 5
• Poor physical fitness is a predisposing factor that increases attack susceptibility 1
• Regular exercise (40 minutes three times weekly) is as effective as topiramate or relaxation therapy for migraine prevention 3, 4
• Ideal physical activity levels could prevent approximately 0.81% of migraine cases 5

Medication Overuse

• Medication overuse headache (MOH) is the most severe complication and risk factor for chronic migraine, occurring when acute medications are used ≥10 days per month 3, 8, 9, 2
• Overuse of ergotamine, triptans, opioids, or combinations for 10 or more days per month leads to exacerbation of headache and transformation to chronic migraine 8, 9
• Acute medication use must be strictly limited to no more than twice weekly to prevent medication overuse headache 3
• MOH frequently mimics chronic migraine and requires withdrawal of overused medications before initiating preventive therapy 3

Stress and Psychological Factors

• Stress is among the most common triggers mentioned in patient surveys and diary studies 6
• "Letdown" after stress has been clinically verified as a migraine trigger 6
• Stress management through cognitive-behavioral therapy, biofeedback, and relaxation techniques should be offered to all patients 3, 4

Dietary and Lifestyle Factors

• Fasting has been clinically verified as a migraine trigger 6
• Alcohol consumption is among the most common factors mentioned in patient surveys 6
• Eating regularly and maintaining adequate hydration are essential preventive measures 4, 7
• Avoiding excessive caffeine, alcohol, and nicotine is recommended 10

Comorbidities as Risk Factors

• Depression, anxiety, and other psychiatric conditions are significant comorbidities that increase migraine risk and must be identified and treated, as their management directly improves migraine outcomes 3, 4, 2
• Cardiovascular disease and cardiovascular risk factors are important considerations, particularly in older patients 1
• Chronic pain conditions represent overlapping comorbidities that worsen migraine burden 3, 4
• Sleep disorders beyond poor sleep hygiene require specific treatment 3, 4

Environmental and Trigger Factors

• Weather changes and low barometric pressure are among the most likely natural triggers, though they are not easily modifiable 6
• Premenstrual periods in women have been clinically verified as triggers 6
• True trigger factors are often self-evident and should not be conflated with aggravating factors (such as physical activity during an attack) 1

Cardiovascular Health Score

• Poor Life's Essential 8 (LE8) scores, based on American Heart Association guidelines for cardiovascular health, are associated with higher migraine risk 5
• High cardiovascular health scores reduce migraine risk by 27% compared to low scores 5
• If all individuals adhered to higher categories of healthy lifestyle and LE8, approximately 11.38% and 22.05% of migraine cases could be prevented, respectively 5

Critical Clinical Pitfalls

• Do not overemphasize trigger avoidance, as this can lead to unnecessary avoidance behavior that damages quality of life 1
• Distinguish between premonitory symptoms (such as neck pain, fatigue, and sensory sensitivities) and true triggers, as premonitory symptoms may mimic triggers 6
• Recognize that many common triggers are not easily modifiable, and avoiding triggers may not be realistic in practice 6
• Focus on healthy lifestyle choices (exercise, adequate sleep, stress management, regular eating) rather than rigid trigger avoidance, as these prevent transformation to chronic migraine over time 6