Migraine Prevention (Prophylaxis)

Authors:

Muhammad Roshan Asghar MD,

Muhammad Umair MD,

Junaid Kalia MD

Introduction

• Recurrent migraines can be functionally impairing and can adversely effect quality of life

• After treating migraines acutely, patients should be evaluated for preventive therapy

Goals of Preventive Therapy

• Reduce attack severity, frequency, and duration

• Improve function and quality of life

• Increase responsiveness to acute headache therapy

• Improve cost-effectiveness of migraine treatment

Indications of Preventive Therapy

• Recurrent migraine that significantly impairs the quality of life and the patient's functionality, despite prompt treatment of acute attacks

• Frequency of migraine attacks ≥1

• Frequency of acute headache medication use ≥2 days/week

• Failure of, contraindications to, or severe side effects from acute migraine therapy

• Overuse of acute medication

• Presence of special circumstances such as hemiplegic or basilar migraine, or attacks with risk of permanent neurological injury

• Patient preference

Principles of Preventive Therapy

• Start with a low dose and increase slowly

• Use an adequate trial of 2 to 3 months

• Avoid medication interaction or contraindications

• Monitor with headache diary

• Monitor for overuse of medication

• Consider comorbid conditions

• Consider combination preventive therapy in refractory patients

• Wean-off medication when headaches are under control

Types of Preventive Treatments

Preventive Medications

Table 1: First-Line Drugs

Table 2: Second-Line Drugs

Behavioral Therapy

Indications

• Patient preference

• Poor tolerance to drugs

• Failure of response or contraindications to medication

• Pregnant or nursing mothers

• Medication overuse

• Significant stress or poor coping mechanisms

Modalities

• Relaxation training

• Cognitive behavioral training

• Biofeedback therapy

Lifestyle Changes

• Good sleep hygiene

• Proper hydration

• Regular exercise

• Effective stress management

• Avoidance of triggers

• Reduction or elimination of caffeine from diet

Supplements/Nutraceuticals

• Vitamin B2 (Riboflavin); 400 mg daily

• Magnesium; 400-500 mg daily

• Co-enzyme Q10; up to 100 mg tds

• Vitamin D; 50,000 IU per week

• Melatonin; 3 mg daily

• Feverfew (Tanacetum Parthenium)

• Omega-3 fatty acids

Preventive Treatment of Menstrual Migraine

• Peri-menstrual use of standard preventive drugs

• Peri-menstrual use of non-standard preventive drugs
• NSAIDs
• Ergot alkaloids
• Triptans
• Magnesium

• Hormonal Therapy
• Combined oral contraceptives
• Estrogens
• Danazol or other synthetic androgens
• Selective estrogen receptor modulators (e.g. Tamoxifen)
• GnRH analogues (medical oophorectomy)

• Dopamine agonists (e.g. Bromocriptine)

Migraine Prevention during Pregnancy

• Safest drug to use is Metoprolol

• Magnesium and non-drug modalities such as relaxation techniques, biofeedback, and acupuncture can be also be used

Conclusion

• Migraine prophylaxis is a relatively safe and effective method of reducing attack frequency and, hence, the affliction of migraine.

• The drugs of first choice are the beta blockers; propranolol and metoprolol, flunarizine, and the anticonvulsant drugs; valproic acid and topiramate.

• The second-line drugs are, among others, amitriptyline, naproxen, butterbur root, gabapentin, and magnesium.

• Prophylactic treatment can even be given for subtypes of migraine, migraine during pregnancy, chronic migraine, and menstrual migraine.

Further Reading

• Dodick, D. W., & Silberstein, S. D. (2007). Migraine prevention. Practical Neurology, 7(6), 383-393. https://doi.org/10.1136/jnnp.2007.134023

Bibliography

1. Migraine prophylaxis - StatPearls - NCBI bookshelf. (2020, October 27). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK507873/

2. Preventive pharmacotherapy in migraine (2013, November 21). American Headache Society. https://doi.org/10.1111/head.12273

3. Bigal, M. E., Krymchantowski, A. V., & Rapoport, A. M. (2004). Prophylactic migraine therapy: Emerging treatment options. Current Pain and Headache Reports, 8(3), 178-184. https://doi.org/10.1007/s11916-004-0049-1

4. Evers, S. (2008). Treatment of migraine with prophylactic drugs. Expert Opinion on Pharmacotherapy, 9(15), 2565-2573. https://doi.org/10.1517/14656566.9.15.2565

5. Yoon, M. S., Savidou, I., Diener, H. C., & Limmroth, V. (2005). Evidence-based medicine in migraine prevention. Expert Review of Neurotherapeutics, 5(3), 333-341. https://doi.org/10.1586/14737175.5.3.333

6. Alstadhaug, K. B., & Andreou, A. P. (2019). Caffeine and primary (Migraine) headaches—Friend or foe? Frontiers in Neurology, 10. https://doi.org/10.3389/fneur.2019.01275

7. Spotlight on: Nutraceuticals. (2020, June 15). American Migraine Foundation. https://americanmigrainefoundation.org/resource-library/nutraceuticals/

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