What are the recommended conservative management strategies for a patient with migraines?

Conservative Management for Migraines

Lifestyle Modifications and Trigger Management (First-Line for All Patients)

All patients with migraine should begin with lifestyle modifications and trigger identification before or alongside pharmacological interventions. 1

Essential Lifestyle Changes

• Establish a regular sleep schedule with consistent bedtimes and wake times to prevent migraine attacks 1
• Maintain adequate hydration throughout the day, as dehydration is a common migraine trigger 1
• Eat well-balanced meals at regular intervals; skipping meals can precipitate attacks 1
• Engage in regular exercise, which has been shown to be as effective as pharmacological approaches when combined with other interventions 1
• Implement stress management techniques including relaxation therapy, biofeedback, and cognitive-behavioral therapy 1, 2

Dietary Modifications

• Limit salt/sodium intake, particularly important for patients with vestibular migraine symptoms 1
• Avoid excessive caffeine, alcohol, and nicotine, all of which can trigger or worsen migraine attacks 1
• Identify and avoid individual food triggers through systematic elimination and headache diary tracking 1

Critical Monitoring Tool

• Maintain a headache diary to track attack frequency, severity, duration, triggers, and treatment response—this is essential for optimizing management 3, 4

Non-Pharmacological Therapies

Behavioral Interventions (Evidence-Based)

Biobehavioral therapy can be as effective as pharmacological approaches and should be combined with medication for optimal outcomes. 1

• Cognitive-behavioral therapy has favorable evidence for migraine prevention 2
• Biofeedback is a first-line non-pharmacological option with strong evidence 2
• Relaxation therapy reduces attack frequency and severity 2
• Stress reduction techniques should be taught to all patients as part of comprehensive management 1

Nutraceuticals and Supplements

• Magnesium citrate has favorable evidence for migraine prevention with minimal side effects 2
• Riboflavin (vitamin B2) is supported by evidence for preventive therapy 2
• Coenzyme Q10 has documented efficacy for migraine prevention 2

Alternative Therapies

• Acupuncture has some supporting evidence for migraine prevention, though not superior to sham acupuncture 1
• Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medications are contraindicated 1
• Vestibular rehabilitation may be useful for patients with chronic imbalance between attacks 1

Patient Education and Self-Management

Patient education is essential to improve understanding and adherence to treatment plans. 1

Key Educational Points

• Explain the biological basis of migraine as a neurological disorder requiring multimodal therapy 1
• Set realistic expectations that efficacy of preventive treatments takes several weeks to months, not immediate relief 1
• Teach proper acute medication use: early administration during the headache phase maximizes effectiveness 5, 6
• Educate about medication overuse headache risk: limit NSAIDs to <15 days/month and triptans to <10 days/month 1, 3

Comorbidity Management

Identify and manage modifiable risk factors that worsen migraine burden: 1

• Obesity (weight control improves outcomes)
• Obstructive sleep apnea
• Anxiety and depression
• Caffeine overuse
• Medication overuse

Critical Pitfalls to Avoid

Medication-Related Pitfalls

• Never use opioids or barbiturate-containing compounds regularly due to dependency risk, rebound headaches, and progression to chronic migraine 7, 1, 6
• Avoid overuse of vestibular suppressant medications for long-term management 1
• Do not abandon preventive treatment prematurely—efficacy requires 2-3 months at therapeutic dose to establish 1, 5

Management Pitfalls

• Failure to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances worsens outcomes 1
• Inadequate follow-up to assess treatment response should be avoided—reassess every 2-3 months initially 1
• Simplified dosing schedules improve adherence—complexity is a barrier to successful treatment 1

When to Consider Preventive Therapy

Preventive therapy should be evaluated when patients experience: 7

• Two or more migraine attacks per month producing disability for ≥3 days
• Use of rescue medication more than twice weekly
• Failure of or contraindications to acute treatments
• Presence of uncommon migraine conditions (prolonged aura, hemiplegic migraine)
• Patient preference for prevention over acute treatment

Integration with Pharmacological Management

While this answer focuses on conservative management, conservative approaches should be combined with appropriate pharmacological therapy rather than used in isolation for most patients. 1 The combination of non-pharmacological and pharmacological approaches is more effective than either alone. 4

Treatment adherence improves with simplified regimens and patient education about realistic timelines for improvement. 1 Failure of one treatment approach does not predict failure of others, so persistence with systematic trials is essential. 1