Migraine Prevention
FACTORS THAT INCREASE THE RISK OF DEVELOPING MORE FREQUENT MIGRAINES
Migraine Risk Factors and Management Strategies
-
Risk Factors:
-
Obesity, psychiatric conditions, sleep problems, excessive caffeine intake, female gender, lower socioeconomic status, other pain disorders, head or neck injury history, allodynia (heightened sensitivity), frequent migraines, ineffective treatment, excessive use of migraine medications, and major life events.
-
Factors such as obesity, psychiatric conditions, sleep disorders, and medication overuse headaches are avoidable.
-
-
Caffeine:
-
While potentially helpful for treating migraines, regular use may lead to withdrawal headaches and increased frequency.
-
Stopping caffeine for 2-3 months, with a gradual taper for heavy users, may improve migraine burden.
-
-
Alcohol
-
Migraine sufferers often find that alcohol can trigger or exacerbate headaches. Understanding the relationship between alcohol and migraines involves considering various factors:
-
Red wine, beer, whiskey, and other alcoholic beverages can induce migraines. Different types of alcohol may have varying effects. For example, red wine contains tyramine, histamine, and sulfites, which are known migraine triggers.
-
Excessive drinking or binge drinking is more likely to trigger headaches.
-
Alcohol is a diuretic, potentially leading to dehydration, which is a known headache trigger.
-
Some studies suggest that alcohol can lead to vasodilation (widening of blood vessels), which may contribute to migraines
-
Responses to alcohol vary among individuals. Some people may experience migraines even with small amounts, while others may be more tolerant.
-
Irregular or infrequent alcohol consumption may pose a higher risk of triggering migraines compared to moderate, consistent intake.
-
Management::
-
Identify specific triggers within alcoholic beverages (e.g., red wine, certain cocktails) and monitor individual responses.
-
Moderation in alcohol consumption can be key. Limiting intake may help reduce the risk of migraines.
-
Counteract dehydration effects by drinking water alongside alcoholic beverages.
-
Opt for beverages with lower migraine risk, such as clear spirits or those with lower histamine and tyramine content.
3. Medication Overuse:
-
Overusing acute headache medications, including analgesics, contributes to increased migraine frequency.
4. Sleep Issues:
-
Insomnia and sleep apnea are common and can worsen migraines.
-
Treating these problems, such as with behavioral therapy for insomnia or CPAP for sleep apnea, can reduce migraine frequent
5. Obesity:
-
Moderate obesity is associated with a higher migraine risk.
-
Weight loss may decrease migraine frequency.
-
Monitoring Medication Effects:
-
Monitoring the effects of migraine medications on weight is advised.
-
-
Management Strategies:
-
Identifying and addressing these risk factors can improve overall migraine management.
-
LIFESTYLE MODIFICATION AND TIGGER AVOIDANCE
To manage migraines effectively, consider incorporating these lifestyle practices:
-
Regular Sleep: Establish a consistent sleep schedule to support a well-regulated sleep pattern.
-
Regular Meals: Eat balanced, regular meals to avoid potential triggers linked to irregular eating habits.
-
Aerobic Exercise: Engage in aerobic exercises, aiming for 150 minutes per week of moderate-intensity activity. This has shown to reduce headache frequency and severity while enhancing overall quality of life.
-
Stress Management: Maintain a consistently low-stress lifestyle to minimize a known trigger for migraines.
-
Migraine Diary: Keep a migraine diary to track frequency, treatment patterns, and potential triggers. Common triggers include stress, weather changes, hormonal fluctuations, skipping meals, alcohol, sleep disturbances, odors, light, smoke, heat, and certain foods. Foods like MSG, processed meats, aged cheese, and artificial sweeteners are often cited as triggers. Be mindful of caffeine intake, as both overdose and withdrawal can be linked to headaches and migraines.
Incorporating these practices may contribute to a more stable and migraine-friendly lifestyle.
Medications and Nutraceuticals with evidence of efficacy
||---------Medication---------------|----------------Daily Dose----------|-------Level of Efficacy-----------|
| Metoprolol | 100 - 200 mg | A |
| Propranolol | 80 - 240 mg | A |
| Topiramate | 50 - 200 mg | A |
| Amitriptyline | 10 - 200 mg | A |
| Timolol | 20 - 60 mg | A |
| Nadolol | 20 - 60 mg | A |
| Divalproex Sodium | 500 - 2000 mg | A |
| Venlafaxine | 75 - 225 mg | B |
| Atenolol | 50 - 200 mg | B |
| Gabapentin | 600 - 3000 mg | U |
| Candesartan | 16 - 32 mg | C |
| Lisinopril | 10 - 40 mg | C |
| Flunarazine | 5 - 10 mg | N/A |
| Pizotifen | 1.5 - 4 mg | N/A |
| Verapamil | 120 - 240 mg | U |
| Onabotulinum A (Botox) | 155 units every 12 weeks | A |
| Erenumab | 70 mg or 140 mg/ month | N/A |
Note:
-
Level of Efficacy:
-
A: Established as effective.
-
B: Probably effective.
-
C: Possibly effective.
-
U: Data is insufficient to assess efficacy.
-
-
N/A: Not applicable (for preventive medications with different mechanisms such as flunarizine, pizotifen, and erenumab).
Nutraceuticals
Coenzyme Q10, Magnesium citrate, riboflavin, and feverfew
CGRP monoclonal antibodies
-
Erenumab: FDA approved
-
Therapies in the pipeline: Small-molecule CGRP antagonist, therapies that target pituitary adenylate cyclase-activating polypeptide, kappa opioid receptors, nitric oxide synthetase, orexins, and glutamate.
Updated CHS guidelines for migraine prevention
The Canadian Headache Society (CHS) has recently updated its guidelines for migraine prevention, reflecting advancements in treatment options and new clinical evidence.
Key Updates:
-
Anti-CGRP Agents: The guidelines incorporate anti-calcitonin gene-related peptide (CGRP) therapies, approved by Health Canada between 2018 and 2024, as options for preventing both episodic and chronic migraines.
-
Chronic Migraine Treatments: Recommendations include the use of propranolol, topiramate, onabotulinumtoxinA, and anti-CGRP agents for chronic migraine prevention. Notably, topiramate's recommendation has been downgraded to a weak endorsement for use in episodic migraine.
-
Newly Recommended Therapies: The guidelines now weakly recommend memantine, levetiracetam, enalapril, and melatonin for episodic migraine prevention, expanding the range of therapeutic options.
Anti-CGRP (calcitonin gene-related peptide) agents, approved for migraine prevention
Several anti-CGRP (calcitonin gene-related peptide) agents are approved for migraine prevention in Canada. Here are the available options along with their dosing information:
Aimovig (Erenumab):
Administered as a subcutaneous injection, the recommended dose is 70 mg once monthly. Some patients may benefit from a higher dose of 140 mg monthly.
Ajovy (Fremanezumab):
Given as a subcutaneous injection, it can be administered either as 225 mg monthly or 675 mg every three months.
Emgality (Galcanezumab):
For migraine prevention, the initial dose is a loading dose of 240 mg (administered as two consecutive 120 mg injections), followed by 120 mg monthly.
Vyepti (Eptinezumab):
Administered via intravenous infusion, the recommended dose is 100 mg every three months. Some patients may benefit from a dose of 300 mg every three months.
Qulipta (Atogepant)
An oral tablet taken once daily, available in strengths of 10 mg, 30 mg, and 60 mg.
Neurostimulation
-
Researchers are studying various methods to prevent migraines, and some of the current approaches include using devices like transcranial magnetic stimulation, transcutaneous supraorbital nerve stimulation, sphenopalatine ganglion stimulation, implanted stimulators for occipital and supraorbital nerve stimulation, transcutaneous vagal nerve stimulation, percutaneous mastoid electric stimulation, and caloric vestibular stimulation.
-
Among these, transcutaneous supraorbital nerve stimulation, transcranial magnetic stimulation, and caloric vestibular stimulation have received clearance from the U.S. Food and Drug Administration (FDA). These devices are designed to be used on a daily basis as part of a preventive strategy for managing migraines.
INDICATIONS FOR ADDITIONAL MIGRAINE PREVENTION
Indications for Additional Migraine Prevention:
-
Three or more moderate to severe headaches per month causing functional impairment.
-
6-8 headache days per month, even with effective acute medications.
-
Contraindications to usual migraine treatments.
-
Bothersome symptoms despite infrequent attacks (e.g., migraine with brainstem aura, hemiplegic migraine).
-
Significant impact on life despite lifestyle changes and acute treatments.
-
Risk of developing medication overuse headaches.
Migraine Preventive Treatment:
-
Decision based on evidence of effectiveness, tolerability, safety, cost, comorbidities, potential interactions, and past experiences.
-
Treatment effectiveness and side effects are crucial for patient satisfaction.
-
Goals include reducing migraine frequency and severity while minimizing side effects.
Patient Considerations:
-
3 or more moderate to severe headaches disrupting daily life.
-
6-8 headache days monthly, even with effective acute medications.
-
Inability to use typical migraine treatments due to health issues.
-
Bothersome symptoms despite infrequent attacks.
-
Significant impact on life despite lifestyle changes and acute treatments.
-
Risk of medication overuse headaches.
Choosing Preventive Treatment:
-
Consider evidence of effectiveness, tolerability, safety, cost, health status, potential interactions, and past experiences.
-
Goals: reduce migraine frequency and severity while minimizing side effects.
-
Open communication with healthcare provider about concerns and side effects is crucial for optimal care.
Additional Therapies
Behavioral Therapy and Combination Approaches for Migraine Prevention:
-
Behavioral Therapy:
-
The American Academy of Neurology recommends Grade A therapies for migraine prevention, including relaxation training, thermal biofeedback with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy (CBT).
-
-
Combination Therapy:
-
Combining medication with behavioral therapies has shown greater benefits, as demonstrated in a study combining propranolol and CBT.
-
-
Combination Approaches:
-
Combining medication with nutraceuticals, neurobehavioral therapy, or noninvasive neurostimulation may be effective for refractory patients on monotherapy.
-
Use medications with different mechanisms of action in combination, based on medical evidence (though not all combinations may be more effective, e.g., propranolol and topiramate together did not show added benefits).
-
-
Intent of Combination Therapy:
-
Combining two medications aims for greater effectiveness rather than addressing side effects of the first medication.
-
-
Adherence and Persistence:
-
Adherence to oral migraine preventive medication is low (26-29% at 6 months, 17-20% at 12 months), often due to side effects and perceived lack of efficacy.
-
Educating patients about persistence with medication can lead to decreased side effects and improved effectiveness over time.
-
-
Adjusting Treatment:
-
If preventative therapy becomes ineffective after 2-3 months at the target dose, consider discontinuation or dose adjustment.
-
Effective preventative therapy should be continued for at least 3 to 6 months before considering discontinuation or tapering.
-