What are the risk factors for migraines?

Risk Factors for Migraine

Migraine risk factors span non-modifiable demographic characteristics and critically important modifiable factors, with obesity, medication overuse, and poor sleep being the most actionable targets for preventing disease progression from episodic to chronic migraine.

Non-Modifiable Risk Factors

• Female sex is a major risk factor, with hormonal fluctuations playing a central role—menstruation is a particularly important trigger for many women who experience exclusively or frequently menstruation-related attacks 1
• Age-related patterns show migraine prevalence increases during adolescence, though it often remits with older age 1
• Family history substantially increases individual risk 1
• Race and ethnicity represent fixed demographic factors that influence migraine susceptibility 2

Critical Modifiable Risk Factors

Obesity and Metabolic Factors (Highest Priority)

• Obesity is the single most critical modifiable risk factor for transformation from episodic to chronic migraine and must be aggressively addressed 1, 3
• Weight loss is particularly crucial in obese patients, making topiramate an especially beneficial preventive choice due to its weight loss effect 1
• Metabolism-related comorbidities represent established risk factors for migraine progression 4

Medication Overuse (Most Severe Complication)

• 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 1
• Acute medication use must be strictly limited to no more than twice weekly to prevent medication overuse headache 1, 3
• MOH frequently mimics chronic migraine and requires withdrawal of overused medications before initiating preventive therapy 3
• Poorly optimized acute headache treatment represents good evidence as a risk factor for progression 4

Sleep Disturbances

• Poor sleep quality and irregular sleep patterns are major predisposing factors that increase susceptibility to migraine attacks 1
• Regular sleep schedules should be emphasized as a core intervention 1
• Sleep disorders beyond poor sleep hygiene require specific treatment 1, 4

Physical Activity and Sedentary Behavior

• Poor physical fitness is a predisposing factor that increases attack susceptibility 1
• Physical inactivity represents an established risk factor with good evidence 4
• Regular exercise (40 minutes three times weekly) is as effective as topiramate or relaxation therapy for migraine prevention 1

Stress and Psychological Factors

• Stress management through cognitive-behavioral therapy, biofeedback, and relaxation techniques should be offered to all patients 1
• Stressful life events are identified remediable risk factors for progression 2
• Selected psychiatric symptoms have good evidence as risk factors for migraine progression 4

Dietary and Lifestyle Factors

• Eating regularly and maintaining adequate hydration are essential preventive measures 1
• Former/current high caffeine intake represents a risk factor with good evidence 4
• Avoiding excessive caffeine, alcohol, and nicotine is recommended 1
• Tobacco use is an established risk factor for progression 4

Migraine Disease Characteristics as Risk Factors

• Frequency of migraine attacks itself is an identified remediable risk factor—higher baseline attack frequency predicts progression 2, 4
• Cutaneous allodynia has good evidence as a risk factor for progression 4
• Personal triggers, when not properly managed, contribute to progression risk 4

Comorbidities as Risk Factors

Psychiatric Conditions

• Depression and anxiety are significant comorbidities that increase migraine risk and must be identified and treated, as their management directly improves migraine outcomes 1, 3
• Depression is specifically identified as a remediable risk factor 2

Pain Conditions

• Extra-cephalic chronic pain conditions have good evidence as risk factors for progression 4
• Chronic pain conditions represent overlapping comorbidities that worsen migraine burden 1

Cardiovascular and Respiratory

• Cardiovascular disease and cardiovascular risk factors are important considerations, particularly in older patients 1
• Respiratory conditions are established risk factors for progression 4

Other Medical Comorbidities

• Neurological and autoimmune diseases represent proposed biological risk factors 5
• Hormonal imbalances contribute to migraine development 5

Socioeconomic Factors

• Financial constraints have good evidence as a risk factor for migraine progression 4

Critical Clinical Pitfall

• Do not overemphasize trigger avoidance, as this can lead to unnecessary avoidance behavior that damages quality of life 1
• The focus should be on modifiable risk factors with the strongest evidence: obesity, medication overuse patterns, sleep hygiene, and regular physical activity rather than obsessive trigger avoidance