Migraine Headache: Prophylactic Treatment

Prophylactic therapy for migraine is aimed at reducing the frequency, and possibly severity, of recurrent migraine headaches. To maximize tolerability, it is important to start with low doses and titrate slowly ( Table 66.1 ). Patients should be given realistic expectations of the benefit likely to be achieved (about 50% improvement in general) and the time to achieve benefit (often 1–3 months). Keeping a headache diary helps evaluate therapeutic response more objectively.

A.

Keeping a regular schedule for meals and sleep hours (including weekends), exercising regularly, and reducing stress are central aspects of migraine prevention. Careful attention to the frequency with which acute medications are used, including over-the-counter medications, is important to avoid medication overuse headache. If migraine headache frequency is greater than 1 day per week, consider starting a prophylactic medication.
B.

Choice of preventive therapy depends on migraine frequency and severity, as well as patient preference and comorbidities. For patients who do not have significant migraine-related disability or functional impairment such as missed school, work, family or social activities, choosing a treatment with few side effects but potentially lesser efficacy is reasonable (e.g., magnesium or riboflavin). For those with significant migraine-related disability, preventive therapy is often selected based on comorbidities and patient preference ( Table 66.1 ). For example, some medications have additional effects that may be desirable in certain cases, such as weight loss in patients with obesity or sedation in patients with insomnia. Reduction in heart rate with β-blockers may be desired in a patient with anxiety but undesired in an athlete. While it is appealing to use a single medication to address multiple conditions, avoid compromising optimal disease management by choosing a less effective medication purely for this reason.
C.

Chronic migraine, defined as 15 or more days with headache per month for 3 months or longer, is usually more difficult to treat than episodic migraine. Most standard prophylactic treatments for episodic migraine can also be tried in chronic migraine, but only botulinum toxin, topiramate, and calcitonin-gene-related peptide (CGRP) inhibitors have demonstrated efficacy in chronic migraine in randomized control trials. Route and frequency of administration of each of these treatments, as well as cost, play an important role in choosing therapy.
D.

Neuromodulation has emerged as an alternative or complement to other established preventive treatments. Multiple neuromodulation therapies have been tested and may have a role in migraine prophylaxis, acute migraine treatment, or both (transcutaneous trigeminal nerve stimulation, noninvasive vagus nerve stimulation, minimally invasive sphenopalatine ganglion stimulation, subcutaneous occipital nerve stimulation). However, some of these devices are still undergoing clinical trials and/or are of uncertain long-term benefit in migraine prevention. Peripheral cranial nerve blockade and trigger point injections with lidocaine and/or bupivacaine are also used for migraine prophylaxis. The most common targets are the greater and lesser occipital nerves. The trigeminal branches (auriculotemporal, supraorbital, and supratrochlear nerves) can also be blocked.