About Me

header ads

Prophylactic Therapies for Migraines

Prophylactic therapy selection in migraines is very important to reduce the frequency and severity of migraine attacks. Also, to reduce stress levels due to recurring headaches. Prophylactic therapy will also ultimately improve the quality of life of patients and prevent the progression of chronic migraine.

Migraine is a recurrent headache caused by neurological and vascular disorders. Epidemiologically, migraines are more commonly experienced by women than men, with a ratio of 3: 1. More than 80% of migraine sufferers have migraine attacks before the age of 30, of which 70% have migraine attacks in the family.

Migraine therapy is divided into two, namely abortive therapy and prophylactic therapy.  As many as 38% of patients with episodic migraine require prophylactic therapy, but only about 13% of patients get it.


A. Criteria of Patient

Prevention of migraine can be done by conservative therapy and pharmacological therapy. In deciding when a patient needs pharmacological therapy to prevent migraine attacks, some criteria can be used as guidelines, namely:

- Patients with more than four headache attacks per month, or at least eight headache days per month
- Acute attacks are very disturbing, even with adequate acute management
- Patients who cannot tolerate or have contraindications to acute migraine attacks drugs
- Patients have the risk of experiencing medication-overuse headache
- Patient preferences
- The presence of specific migraine subtypes, such as migraine hemiplegia, migraine with brainstem aura, migrainous infarction, and severe, persistent aura symptoms.


B.Medical Prophylactic Therapies for Migraines

It should be noted that medicines used for migraine prophylactic are also used in the management of other diseases, such as epilepsy, hypertension, and depression. So, doctors need to provide clear information to patients to they are not confused.

Beta blocking drugs, such as propranolol and atenolol, can be used in therapies for migraine prophylaxis. However, their side effect, such as orthostatic intolerance, must be considered. Other drugs that can be used in migraine prophylaxis are amitriptyline, lisinopril, and verapamil.

Nutrition can also be used in prophylactic migraine therapy. Examples of nutritional alternatives that can be chosen are coenzyme Q10, magnesium sulfate, riboflavin, and feverfew.

According to AFP,  based on scientific evidence, the effective first-line drugs for migraine prophylaxis are Divalproex, topiramate, metoprolol, propranolol, and timolol. Other drugs that can be used as second-line therapy are amitriptyline, venlafaxine, atenolol, and nadolol. There is still limited evidence regarding the efficacy of bisoprolol, carbamazepine, gabapentin, fluoxetine, nicardipine, verapamil, lisinopril, and candesartan. While acebutolol, oxcarbazepine, lamotrigine, and telmisartan have proven to be effective.

The latest modality, the FDA has approved a drug that targets calcitonin gene-related peptide pain transmission. However, further studies related to long-term efficacy and side effects are still needed.


C. Non-medicamentous Prophylactic Therapies in Migraines

Besides drugs, other procedures can be recommended to prevent migraines such as neurostimulation, behavioral therapy, and avoidance of triggers.

1. Neurostimulation
Several neurostimulation procedures have been reported to have a positive impact on migraine prevention. The FDA has approved procedures for supraorbital nerve transcutaneous stimulation, transcranial magnetic stimulation, and vestibular caloric stimulation. However, scientific evidence regarding these procedures is still limited.

2. Behavior Therapy
Behavioral therapies, such as relaxation exercises, electromyographic biofeedback, and cognitive-behavioral therapy (CBT), are recommended as prophylactic migraine therapy. Behavioral therapies are especially recommended for patients who cannot tolerate pharmacological therapy, have contraindications, or patients with stress as the primary triggers of migraine attacks.

3. Avoid precipitating factors
Some factors that can trigger migraines are caffeine consumption, excessive use of acute headache medications, and irregular sleep patterns.

- Caffeine Consumption:
Caffeine consumption and migraine attacks have a complicated relationship. Caffeine can be an effective therapy in relieving migraine attacks. However, excessive caffeine consumption and sudden cessation of caffeine consumption can also be a trigger for migraines because caffeine acts as an antagonist of the adenosine receptor.

- Excessive Use of Acute Headache Medication:
Excessive use of pain medication can trigger a more severe headache (medication overused headache). This condition is defined as the use of simple analgesic therapy for ≥ 15 days a month or the use of specific analgesic therapy (such as triptan, dihydroergotamine, opioids) for ≥ 10 days in one month.

- Irregular Sleep Patterns:
Sleep is one of the non-medicamentous management options considered effective in treating migraine attacks. Sleep disturbance can be a trigger factor that increases the frequency and severity of migraine attacks. Many sleep disorders are associated with migraine conditions, including insomnia, poor sleep quality, snoring, and restless leg syndrome.


1. Ha H, Gonzalez A. Migraine headache prophylaxis. Am Fam Physician. 2019;99(1):17-24.
2. Vetvik KG, MacGregor EA. Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. Lancet Neurol. 2017;16(1):76-87.
3. Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology. 2007;68(5): 343–349.
4. Pringsheim T, Davenport W, Mackie G, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 suppl 2):S1–S59.
5. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(6):754–762.
6. Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatr Dis Treat. 2013;9:709-720.
7. Modi S, Lowder DM. Medications for migraine prophylaxis. Am Fam Physician. 2006;73(1):72-78.
8. Schwedt TJ, Vargas B. Neurostimulation for treatment of migraine and cluster headache. Pain Med. 2015;16(9):1827–1834.
9. Cvetkovic VV, Jensen RH. Neurostimulation for the treatment of chronic migraine and cluster headache. Acta Neurol Scand. 2019;139(1):4-17.
10. Miller S, Sinclair AJ, Davies B, Matharu M. Neurostimulation in the treatment of primary headaches. Practical Neurology. 2016;16:362-375.
11. Harris P, Loveman E, Clegg A, Easton S, Berry N. Systematic review of cognitive behavioral therapy for the management of headaches and migraines in adults. Br J Pain. 2015;9(4):213–224.
12. Schwedt TJ. Preventive therapy of migraine. Continuum. 2018;24:1052-65.

Post a Comment

0 Comments