Migraine prevention in adults

Everyday problems sometimes make migraine attacks more likely in people who have them. Examples include:

• too little sleep or poor sleep
• irregular or skipped meals
• stress – or winding down after being stressed out, for instance at weekends
• changes in the weather
• lack of exercise
• in women: changes in hormone levels, for example during their monthly cycle (period)

Certain food or drinks – such as red wine – may also trigger migraine attacks in some people.

Keeping a headache or migraine diary for a few weeks or months can help you find out if something specific is triggering your migraines. You can write down

• what happened just before the migraine attack started,
• what you had to eat or drink beforehand,
• the time the migraine started and when it was over,
• how severe the migraine was, and
• what time you took medication and – if so – what kind of medication, and how much.

If, for instance, you suspect your migraines might be triggered by red wine, you could avoid drinking red wine for a while and then use your diary to see whether you have fewer or milder migraines.

Things that increase the likelihood of migraine attacks don't necessarily trigger them, though. Nowadays experts believe that a combination of various factors contribute to the onset of migraines. Temporary stress, such as problems at home or in the workplace, can make some people particularly susceptible. Others have a migraine attack when things calm down, like at the weekend or the start of vacation.

Sometimes it isn't the stress or sleep problems themselves that cause an attack, but rather how you deal with them. And everyday stress is often unavoidable. The aim of treatments without medication is to help you cope better with stress. Techniques such as progressive muscle relaxation and autogenic training can help you do this. These relaxation techniques can be taught in classes or learned using books, videos or an app.

If migraines are having a major impact on your life, cognitive behavioral therapy is also an option. This treatment involves looking into how your behavior, thoughts and feelings affect the pain you feel – and how to use this to cope better with the pain. So far there aren't many studies on psychological approaches in the treatment of migraine headaches. But cognitive behavioral therapy is a well established treatment for other medical conditions associated with chronic pain.

Biofeedback involves trying to learn to deliberately control subconscious body functions. You can use it to try to influence headaches when they start too. A review of studies suggests that biofeedback could help prevent migraine attacks. But you need to practice the technique a lot for it to be effective. In Germany, statutory health insurers usually don't cover the costs of biofeedback.

As the name suggests, "nerve stimulation" therapy involves stimulating the nervous system to try to influence the transmission of pain signals and pain sensation in the brain. This can be done by sending electronic pulses or magnetic waves to the brain using electrodes on the surface of the scalp. Sometimes individual nerves are stimulated – for example, the nerve that sends messages from the back of the head and neck. There hasn't been enough good research on how effective these kinds of nerve stimulation are at preventing migraines.

Knowing a lot about the condition can make it easier to cope with it. Even just having an in-depth consultation with your doctor can be helpful. Acupuncture might help some people to reduce the frequency of their migraine attacks. Endurance sports like brisk walking, swimming or physical exercise like aerobics are often recommended for prevention, too.

A number of herbal products and dietary supplements are available for the prevention of migraines. These include, in particular, coenzyme Q10, magnesium, feverfew, butterbur, vitamin D and riboflavin (vitamin B2).

There is a lack of conclusive evidence in this area, so it's not possible to say whether these products can prevent migraines. Some studies suggest that magnesium and a certain feverfew extract can reduce the number of migraine attacks. But the quality of these studies isn't good enough to prove that these products have a preventive effect.

Although dietary supplements and herbal medicinal products are often considered to be well tolerated and safe, they may still have side effects. For instance, feverfew extracts can cause gastrointestinal (stomach and bowel) problems. These products can also lead to drug-drug interactions with other medications.

Acute migraine attacks are usually treated using painkillers like acetylsalicylic acid (ASA – the drug in medicines like Aspirin), ibuprofen, acetaminophen (paracetamol) or migraine medicines such as triptans. But these medications aren't suitable for preventing attacks.

Preventive medications are taken every day for a longer period of time, regardless of whether you have acute symptoms or not. The aim is to stop migraine attacks from happening in the first place. Many experts consider preventive medication to be effective if it reduces the number of migraine attacks by half. They recommend using medication for prevention if

• you have three or more debilitating migraine attacks per month,
• the attacks often last longer than three days or are especially severe,
• treatment with painkillers or triptans doesn't help,
• you can't use painkillers or migraine medication for health reasons or because of side effects, or
• you have to use painkillers or migraine medication on more than ten days per month.

Whether or not you would like to use preventive medication is ultimately your decision. It will depend on things like how bad your migraines are and how you weigh the pros and cons of treatment with medication.

Most of the medications used to prevent migraines were originally developed for the treatment of other medical conditions, and were later found to prevent migraines too. They are often taken in lower doses when used for preventive purposes, though. The following medications are typically considered:

• Beta blockers such as metoprolol and propranolol, and the calcium channel blocker flunarizine. These medications inhibit certain enzymes or receptors that also play a role in the development of migraine attacks. They are normally used to treat high blood pressure.
• Anti-seizure drugs (anticonvulsants) such as topiramate and valproate sodium. They are typically used to treat epilepsy.
• Amitriptyline, one of the medications used to treat depression (called tricyclic antidepressants).
• The drug botulinum toxin type A ("Botox") has been approved for the treatment of chronic migraine. Small doses of this medication are injected into about 30 different muscles in the neck and head area.

If these medications aren't tolerated or aren't effective, you could try other medicines like acetylsalicylic acid (the drug in e.g. Aspirin).

Newer medications that can be prescribed for the prevention of migraines in Germany contain antibodies that are produced in a laboratory, and are injected. The antibodies bind to a certain protein in the body that is probably involved in the development of migraine attacks. Three of these medications have been approved for the prevention of migraine attacks in Germany: fremanezumab, galcanezumab and erenumab. But they are only considered as a treatment option if the other medications don’t help enough.

Research has shown that the beta blockers metoprolol and propranolol can reduce the frequency of migraine attacks. For example, studies on propranolol found the following:

• The average number of migraines per month went down by more than half in 23 out of 100 people who took a placebo (fake medication).
• in 46 out of 100 people who took propranolol.

In other words, due to preventive treatment with propranolol, an extra 23 out of 100 people had only half as many migraine attacks per month as they did before. Metoprolol is about as effective as propranolol.

The potential side effects of beta blockers include tiredness, dizziness, sleep problems and gastrointestinal (stomach and bowel) problems. In the studies on metoprolol and propranolol, about 10 out of 100 people who used these drugs had side effects.

The anti-seizure drugs topiramate and valproate sodium have also been shown to prevent migraine attacks. Studies found them to be about as effective as beta blockers. But they have other kinds of side effects. Topiramate can lead to weight loss, tiredness, abnormal skin sensations such as tingling and numbness, and an altered sense of taste. About 6 out of 100 people in the studies stopped their treatment because of such side effects. Valproate sodium can lead to tiredness, dizziness, skin rashes, hair loss and tremors. There is a lack of good research on how common these side effects are. Roughly speaking, about 7 out of 100 people experience dizziness and tremors. The frequency of side effects will also depend on the dose of the drug.

In Germany, topiramate has been approved for the prevention of migraines in adults. Valproic acid has not been approved for this purpose, but it can be used "off-label."

Research in people with chronic migraine has shown that Botox treatment reduces the number of migraine days by two per month – from 13 to 11 days.

Botox injections were also found to reduce the number of migraine attacks in people with episodic migraine more effectively than placebo injections (no active medication) do:

The number of migraine attacks per month went down by more than half

• in 34 out of 100 people who didn't use Botox, and
• in 51 out of 100 people who used Botox.

In other words: Due to preventive treatment with propranolol, an extra 17 out of 100 people had only half as many migraine attacks per month as they did before. But the effect wears off after a few months. The treatment can be repeated every twelve weeks.

Common side effects of this treatment include a stiff neck, neck pain and muscle weakness. About 10 to 15 out of 100 people are affected by these side effects. Other possible side effects include a droopy eyelid and trouble swallowing. This can happen because Botox temporarily "numbs" the nerves. But the side effects don't last. The nerves return to normal when the effect of the drug wears off. About 2 to 3 out of 100 people in the studies stopped their treatment because of such side effects.

In very rare cases, the injections can also lead to more serious complications such as infections or trouble breathing. To avoid problems like this, it's a good idea to find a doctor who has experience with this treatment approach.

Different medications will be more suitable for different people, depending on a number of factors. One commonly used type of drug for the prevention of migraines are beta blockers. Beta blockers also lower your blood pressure, so they are especially suitable for people who need medication to lower their blood pressure anyway. On the other hand, beta blockers aren't very suitable for people who have asthma because they can make their bronchi (airways) narrower.

Women who are pregnant or would like to become pregnant should avoid taking preventive medication for migraines if possible because a number of these drugs can lead to malformations in unborn babies. But treatment with metoprolol is considered to be safe in pregnancy. If used over a longer period of time, though, the growth of the unborn baby should be monitored.

It is important to talk to a doctor about your medication options and the possible interactions with other medications. You don't necessarily have to stop taking medication if you have side effects. There are sometimes other ways to deal with them. If your medication makes you feel tired, for instance, taking it in the evening might help. Some side effects become milder over time too. For example, your circulation may adjust to the blood-pressure-lowering effect of beta blockers after a while, making you feel less dizzy or less tired.

When taking medication for migraine prevention, it's a good idea to start off with a low dose and then gradually increase it. That way, side effects can be reduced or even avoided altogether. It can be helpful to keep a migraine diary when taking medication to get a better idea of whether the medication is working. But even once the target dose has been reached, it can still take up to two months for the number of migraine attacks to go down. If there is still no noticeable improvement after that, it might be a good idea to try a different drug.

The medication must be used daily for quite a long time before it can have a preventive effect. But it's a good idea to have a break from medication after about six to twelve months, to see whether your migraines have improved and whether you still need medication. When you stop taking the medication, it's important to stop gradually rather than suddenly.