Preventive (Prophylactic) Therapy

If your migraine attacks are becoming increasingly more frequent, if you are suffering attacks of disabling migraine despite optimal use of acute therapies, if you are experiencing some degree of headache more days than not, or if your migraine has evolved to the point where you are experiencing headache on a daily or near-daily basis, then it is time to consider prophylactic therapy to reduce attack frequency or, if your migraine has “chronified” and become daily or near-daily, suppression therapy to help you achieve remission back to episodic migraine.

As with acute migraine treatment, migraine prevention/suppression therapy may involve nonpharmacologic measures as well as medications; examples of the former include an aerobic conditioning program, avoidance of migraine attack “triggers” and striving to maintain good sleep hygiene. While acute migraine may respond to nonpharmacologic interventions alone, chronic migraine typically requires effective use of both medications intended for acute migraine treatment and medications for prevention/suppression. Before a specific medication for prevention/ suppression is selected, there are some important treatment issues to keep in mind:

• Take an adequate dose of the medication for an adequate duration

Many patients come to clinic and report they have failed “everything” they have tried for migraine prevention/suppression. When asked about specific drugs, however, it often turns out the patient took the given medication only at a very low dose and for only a short period of time, discontinuing therapy because of side effects, lack of improvement or both. The orally administered prevention/ suppression therapies known to be effective for migraine prevention/suppression may require a substantial period of treatment at a therapeutic dose to begin to exert any clinically detectable beneficial effect, and in some cases – so as to minimize drug-related side effects – it is necessary to begin treatment at a low dose and subsequently increase to a target dose over a period of weeks. This can be an especially tough time for a patient who is experiencing headache on a daily or near-daily basis. There is no current therapy for migraine prevention/suppression that has better than a coin flip’s (50%) chance of promoting significant improvement, and it is difficult for your physician to predict up-front whether the treatment prescribed will be effective. Thus, pharmacologic treatment intended for migraine prevention/suppression is a matter of educated trial and error, a process which can prove to be frustrating for patients and physicians alike.

• Don’t stick with a loser

If you have been taking an adequate dose of a prevention/suppression medication for an adequate period of time and have not experienced a significant improvement in your headache disorder, then it is either the wrong dose or the wrong drug for you. It is time for a change. Call your doctor.

• Treat “break-through” headache attacks aggressively

Aggressive treatment of acute migraine attacks or intensifications will assist in reducing the likelihood of subsequent attacks and in achieving remission of chronic migraine back to its episodic form. Headache tends to beget headache, and if you are attempting to reduce your attack frequency or reverse the headache chronification process, experiencing prolonged attacks of severe migraine will work against that effort. And remember: treat early!

• Avoid overuse of symptomatic (acute) medication

There is solid scientific evidence to suggest that overuse of symptomatic medication reinforces chronification and that ceasing overuse may be accompanied by clinical improvement. Remember: restrict your use of the simple analgesics to no more than 15 days per month and your use of virtually all prescription medications intended for acute migraine treatment to no more than 10 days per month. Of all the medications available for acute migraine treatment, the nonsteroidal anti-inflammatory drugs appear to have the lowest potential for promoting medication overuse headache.

• Chronic, indefinite use of a medication for prevention/suppression of migraine rarely is required

Many patients will not require chronic treatment with a prevention/suppression therapy for periods exceeding 6 months to a year. The goal of prevention/therapy is “headache-free or nearly so”… again at the cost of no or minimal side effects. Once you have reached that point and remained there for 4 to 6 months, it is quite possible that you can taper off your prevention/ suppression medication and that you will not require such therapy again for months to years.

“To Do” checklist for improving your headache control

1. Initiate (and stick to) an aerobic conditioning program.

2. Keep a careful headache diary.

3. Maintain good sleep hygiene.

4. Eat nutritional, regularly spaced meals.

5. Treat acute attacks of migraine early and aggressively.

6. Don’t overuse symptomatic medication.

7. If you require prevention/suppression therapy, give the specific therapy a decent chance.

8. If you suffer from a migraine “co-morbidity,” such as chronic insomnia, anxiety, depression, or other medical problems, seek treatment for that condition.

9. Regularly set aside time for personal relaxation and stress reduction.

10. Give back . . . to your family, friends, community. No matter how badly your migraine makes you feel, you will deal with your headache disorder more effectively if you are actively engaged in the world around you.

John F. Rothrock, MD

Editor-in-Chief, Headache

Professor and Vice Chair Director,

Headache Treatment and Research Program

University of Alabama

Birmingham, AL, USA