What are the key recommendations for migraine hygiene and management?

Migraine Hygiene: Evidence-Based Lifestyle and Behavioral Recommendations

Migraine hygiene centers on maintaining consistent daily routines and avoiding disruptions to homeostasis, rather than restrictive trigger avoidance, with the strongest evidence supporting regular sleep, meals, hydration, exercise, and stress management as protective factors.

Core Lifestyle Modifications

Sleep Hygiene

• Maintain consistent sleep duration and quality by going to bed and waking at the same time daily, as sleep disturbances are among the most common migraine triggers 1
• Ensure sufficient sleep and aim to wake refreshed, as these factors were associated with decreased migraine attack probability in prospective cohort studies 2

Meal Regularity and Hydration

• Eat regular meals without skipping, as fasting is a verified migraine trigger in clinical studies 1
• Maintain adequate hydration throughout the day, which is one of the most evidence-based lifestyle factors for migraine management 3
• Good adherence to hydration and regular meals was associated with longer disease duration, suggesting these behaviors are learned protective strategies 2

Physical Activity

• Engage in regular moderate to intense aerobic exercise, ideally 40 minutes three times weekly, which has been shown to be as effective as topiramate in clinical trials 4
• Exercise ≥3 times per week is recommended, though this is the least followed recommendation among migraine patients 2
• Regular physical activity was associated with decreased migraine attack risk in prospective tracking studies 2

Stress Management

• Practice stress management with relaxation techniques or mindfulness, as stress is one of the most commonly reported migraine triggers 3, 1
• "Letdown" after stress is a verified trigger in clinical studies, making consistent stress management crucial 1
• Feelings of happiness and relaxedness were associated with decreased migraine attack probability 2

Weight Management

• Pursue weight loss if overweight or obese, as this is part of evidence-based lifestyle factors that may prevent transformation to chronic migraine 3, 1

The Trigger Avoidance Controversy

Current Evidence Against Restrictive Diets

• Do not routinely advise patients to eliminate foods from their diet based on presumed triggers, as there is little to no evidence supporting dietary approaches for migraine management 4
• IgG antibody testing for dietary trigger avoidance is specifically recommended against in headache management 4
• Many presumed "triggers" (caffeine, alcohol, chocolate) actually behaved as protectors in a substantial proportion of individuals in prospective cohort studies 2

Personalized Trigger Identification

• Use a headache diary to track potential triggers alongside other factors (stress, sleep, hormonal changes) rather than implementing blanket dietary restrictions 3, 4
• Headache diaries reduce recall bias and increase accuracy in identifying true individual triggers 5
• Out of 47 tracked triggers, 24 were more often associated with decreased rather than increased migraine attack risk, challenging blanket avoidance recommendations 2

Monitoring and Documentation

Headache Calendar Use

• Maintain a headache calendar prospectively to capture attack frequency, severity, and medication use with minimal time commitment if completed only on symptomatic days 6
• Diaries are valuable for monitoring acute medication use to prevent medication overuse headache 6
• Track attack frequency (measured in headache or migraine days per month), severity, and migraine-related disability 6

Critical Pitfalls to Avoid

Medication Overuse Prevention

• Limit acute medications to no more than 2-3 days per week to prevent medication overuse headache 3
• Be vigilant for rebound headaches from withdrawal of analgesics or triptans 3
• Frequent, repeated use of acute medication risks development of medication overuse headache 6

Comorbidity Management

• Assess for and manage common comorbidities including anxiety, depression, and sleep disorders, as these significantly impact migraine outcomes 3

Realistic Expectations

• Set realistic expectations for treatment outcomes, as many common migraine triggers are not easily modifiable and avoiding triggers may not be realistic 1
• Healthy lifestyle choices may prevent transformation to chronic migraine over time rather than eliminating all attacks 1

Integration with Comprehensive Care

• Combine lifestyle modifications with appropriate pharmacologic treatment when indicated, as dietary and lifestyle interventions alone are insufficient for many patients 4
• Consider preventive pharmacologic therapy for patients with ≥2 migraine attacks per month with significant disability, regardless of lifestyle modifications 4
• Cognitive-behavioral therapy and biofeedback should be part of a multimodal approach alongside lifestyle modifications 4