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 patients' quality of life and prevent the progression of chronic migraine.

Migraine is a recurrent headache caused by neurological and vascular disorders. Epidemiologically, women's migraines are more commonly experienced than men, with a 3: 1. More than 80% of migraine sufferers have migraine attacks before 30 years old, 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, only about 13% of patients get it.

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
  • very disturbing Acute attacks, even with adequate acute management.
  • For patients who cannot tolerate or have contraindications to acute migraine attacks drugs
  • Patients have the risk of experiencing a 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.

Prophylactic Therapies for Migraines

A. Medical Prophylactic Therapies for Migraines

It should be noted that medicines used for migraine prophylactic are also used to manage 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, the effective first-line drugs for migraine prophylaxis are:
  • Divalproex
  • topiramate
  • metoprolol
  • propranolol
  • timolol
Other drugs that can be used as second-line therapy are:
  • amitriptyline
  • venlafaxine
  • atenolol
  • 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.

B. 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:
  • 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
  • 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 trigger 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 using simple analgesic therapy for ≥ 15 days a month or specific analgesic therapy (such as triptan, dihydroergotamine, opioids) for ≥ 10 days in one month.

- Irregular Sleep Patterns:
Sleep is one of the non-medicament 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.

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