Prevention of migraine attacks
Preventive treatment of migraine can be an important component of migraine management. The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraine attacks, and to increase the effectiveness of abortive therapy. Another reason to pursue prevention is to avoid medication overuse headache, otherwise known as rebound headache, which can arise from overuse of pain medications, and can result in chronic daily headache. Preventive treatments of migraine include medications, nutritional supplements, lifestyle alterations, and surgery. Prevention is recommended in those who have headaches more than two days a week, cannot tolerate the medications used to treat acute attacks, or those with severe attacks that are not easily controlled.
Behavioral interventions
Behavioral interventions focus on different methods to change behaviors and can be used alone or along with medications. Exercise for 15–20 minutes per day may be helpful for reducing the frequency of migraine attacks. Recommended lifestyle changes include stopping tobacco use and reducing behaviors that interfere with sleep. Sleep modifications including improving sleep hygiene have been shown to reduce headache frequency in adults with frequent migraines. Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches. General dietary restriction has not been demonstrated to be an effective approach to treating migraine. Sexual activity has been reported by a proportion of males and females with migraine to relieve migraine pain significantly in some cases. CBT, relaxation training, and mindfulness have also been shown to have some effect on mitigating migraine frequency, albeit with limited data on the changes to quality of life. In children and teens, CBT, relaxation training, and biofeedback techniques may reduce the frequency of migraines. Migraines can affect an individuals life in plenty areas. However, behavioral interventions can improve the overall wellbeing of an individual; affecting the extent and negative impact of migraines. A systematic review and meta-analysis showed that in children and adolescents the use of various behavioral interventions such as CBT, biofeedback, and relaxation training has greater effectiveness on migraine frequency reduction than education by itself. However, it is important to note that a 2024 PCORI review found that while these behavioral interventions may reduce migraine frequency, the generalized strength of evidence is low to moderate. Interventions such as biofeedback, acceptance and commitment therapy, and hypnotherapy have not demonstrated enough evidence to determine whether or not they are useful in preventing migraines. In another systematic review, migraine education in adults was also studied as a means for migraine prevention. These studies were unique in that education was used in isolation without any other concurrent treatments. The reports on migraine frequency were mixed, with one study finding a statistically significant effect against education, and another studying reporting that there was a reduction in attacks by 6 migraine days/month compared to the control group.Medications
Preventive drugs are used to reduce the frequency, duration, and severity of migraine attacks. Because of frequent unpleasant and sometimes debilitating side effects, preventive drugs are only prescribed for those migraineurs whose quality of life is significantly adversely affected. The most commonly prescribed drugs for migraine prevention are beta-blockers, antidepressants, and anticonvulsants. The drugs are started at a low dose, which is gradually increased until therapeutic effects develop, the ceiling dose for the chosen drug is reached, or side effects become intolerable.Preventive migraine medications are considered effective if they reduce the frequency or severity of the migraine attacks by at least 50%. Due to few medications being approved specifically for the preventative treatment of migraine headaches, many medications such as beta-blockers, anticonvulsive agents such as topiramate or sodium valproate, antidepressants such as amitriptyline and calcium channel blockers such as flunarizine are used off label for the preventative treatment of migraine headaches. Guidelines are fairly consistent in rating the anticonvulsants topiramate and divalproex/sodium valproate, and the beta blockers propranolol and metoprolol as having the highest level of evidence for first-line use for migraine prophylaxis in adults. Propranolol and topiramate have the best evidence in children; however, evidence only supports short-term benefit as of 2020.
The beta blocker timolol is also effective for migraine prevention and in reducing migraine attack frequency and severity. While beta blockers are often used for first-line treatment, other antihypertensives also have a proven efficiency in migraine prevention, namely the calcium channel blocker verapamil and the angiotensin receptor blocker candesartan.
Tentative evidence also supports the use of magnesium supplementation. Increasing dietary intake may be better. Recommendations regarding effectiveness varied for the anticonvulsants gabapentin and pregabalin. Frovatriptan is effective for prevention of menstrual migraine.
The antidepressants amitriptyline and venlafaxine are probably also effective. Angiotensin inhibition by either an angiotensin-converting enzyme inhibitor or angiotensin II receptor antagonist may reduce attacks.
Medications in the anti-calcitonin gene-related peptide, including eptinezumab, erenumab, fremanezumab, and galcanezumab, appear to decrease the frequency of migraines by one to two per month.
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
Drugs used to prevent migraine in the UK include: fremanezumab, eptinezumab, erenumab, galcanezumab, botulinium toxin A, topiramate. A meta-analysis suggested that all these drugs reduced the number of days people spent with migraine and that differences in effectiveness between these drugs were modest.
The most effective prescription medications include several drug classes.
Beta blockers
The beta-blocker propranalol's effectiveness in headache treatment was a chance finding in patients receiving the drug for angina. The beta-blockers that are used in migraine treatment are propranolol, nadolol, timolol, metoprolol, and atenolol.A meta-analysis found that propranolol had an "overall relative risk of response to treatment " was 1.94.
Adverse drug reactions associated with the use of beta blockers include: nausea, diarrhea, bronchospasm, dyspnea, cold extremities, exacerbation of Raynaud's syndrome, bradycardia, hypotension, heart failure, heart block, fatigue, dizziness, alopecia, abnormal vision, hallucinations, insomnia, nightmares, sexual dysfunction, erectile dysfunction and/or alteration of glucose and lipid metabolism. Due to the high penetration across the blood–brain barrier, lipophilic beta blockers, such as propranolol and metoprolol, are more likely than other, less lipophilic, beta blockers to cause sleep disturbances, such as insomnia and vivid dreams and nightmares.
Neuromodulators
Neuromodulators are also referred to as antidepressants when used to treat depression. Amitriptyline has been more frequently studied of the antidepressants and is the only antidepressant with fairly consistent support for efficacy in migraine prevention. The method of headache prevention with antidepressants is uncertain, but does not result from treating masked depression.Tricyclic antidepressants such as amitriptyline and the newer selective serotonin reuptake inhibitors such as fluoxetine are sometimes prescribed. TCAs have been found to be more effective than SSRIs. SSRIs are no more effective than placebo. Another meta-analysis found benefit from SSRIs among patients with migraine or tension headache; however, the effect of SSRIs on only migraines was not separately reported.
The main two side effects that occur from taking amitriptyline are drowsiness and a dry mouth. Other common side effects of using amitriptyline are mostly due to its anticholinergic activity, including: weight gain, changes in appetite, muscle stiffness, nausea, constipation, nervousness, dizziness, blurred vision, urinary retention, and changes in sexual function.
Anticonvulsants
Anticonvulsant medication is commonly prescribed for migraine prevention, because they have been shown in placebo-controlled double-blind trials to be effective in some migraine sufferers.Anticonvulsants such as valproic acid and topiramate. A meta-analysis by the Cochrane Collaboration of ten randomized controlled trials or crossover studies, which together included 1341 patients, found anticonvulsants had an "2.4 times more likely to experience a 50% or greater reduction in frequency with anticonvulsants than with placebo" and a number needed to treat of 3.8. However, concerns have been raised about the marketing of gabapentin.