Preventive (also called prophylactic) treatment of migraines can be an important component of migraine management. Such treatments can take many forms, including everything from taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers.
The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase the effectiveness of abortive therapy.[1] Another reason to pursue these goals is to avoid medication overuse headache (MOH), otherwise known as rebound headache, which is a common problem among migraneurs. This is believed to occur in part due to overuse of pain medications, and can result in chronic daily headache.[2][3]
Many of the preventive treatments described below are quite effective: Even with a placebo (sham treatment), one-quarter of patients find that their migraine frequency is reduced by half or more, and actual treatments often far exceed this figure.[4]
Maintaining a headache calendar or helpful is useful for patients who need to be on preventative medications. There are paper diaries and electronic diaries such as iPhone app iHeadache, iPhone app Headache Diary, Blackberry app iHeadache, and android app My Migraine Log.
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Patients should attempt to identify and avoid factors that promote or precipitate migraine episodes. Moderation in alcohol and caffeine intake, consistency in sleep habits, and regular meals may be helpful. General dietary restriction has not been demonstrated to be an effective approach to treating migraine.[5] However, eliminating particular foods that are known to trigger migraines in an individual can be very effective.
Some individuals have a condition called celiac disease (or "gluten intolerance") that results in the body incorrectly processing gluten. Studies have suggested that many migraine sufferers have celiac disease, and for those who do, decreasing gluten intake may significantly reduce migraine frequency.[6 ] Celiac disease and gluten sensitivity may be an underlying cause of migraines in some patients, and a gluten-free diet has been demonstrated to reduce, if not completely eliminate, migraines in these individuals. A study of 10 patients with a long history of chronic headaches that had recently worsened or were resistant to treatment found that all 10 patients were sensitive to gluten. MRI scans determined that each had inflammation in their central nervous systems caused by gluten-sensitivity. Seven out of nine of these patients that went on a gluten-free diet stopped having headaches completely.[7] Another study showed that migraneurs were 10 times more likely than the general population to have celiac disease, and that for migraneurs with celiac disease, a gluten-free diet improved blood-flow to the brain and either eliminated migraines or reduced migraine frequency, duration, and intensity.[6 ]
A 2006 review article by S. Modi and D. Lowder offers some general guidelines on when a physician should consider prescribing drugs for migraine prevention:
Following appropriate management of acute migraine, patients should be evaluated for initiation of preventive therapy. Factors that should prompt consideration of preventive therapy include the occurrence of two or more migraines per month with disability lasting three or more days per month; failure of, contraindication for, or adverse events from acute treatments; use of abortive medication more than twice per week; and uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction). Patient preference and cost also should be considered....Therapy should be initiated with medications that have the highest levels of effectiveness and the lowest potential for adverse reactions; these should be started at low dosages and titrated slowly. A full therapeutic trial may take two to six months. After successful therapy (e.g., reduction of migraine frequency by approximately 50 percent or more) has been maintained for six to 12 months, discontinuation of preventive therapy can be considered.
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Preventive medication has to be taken on a daily basis, usually for a few weeks, before the effectiveness can be determined. Supervision by a neurologist is advisable. A large number of medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Often preventive medications do not have to be taken indefinitely. Sometimes as little as six months of preventive therapy is enough to "break the headache cycle" and then they can be discontinued.
The most effective prescription medications include several drug classes:
A wide range of pharmacological drugs have been evaluated to determine their efficacy in reducing the frequency or severity of migraine attacks.[14] These drugs include beta-blockers, calcium antagonists, neurostabalizers, nonsteroidal anti-inflammatory drugs (NSAIDs),tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), other antidepressants, and other specialized drug therapies.[14] The US Headache Consortium lists five drugs as having medium to high efficacy: amitriptyline, divalproex, timolol, propranolol and topiramate.[14] Lower efficacy drugs listed include aspirin, atenolol, fenoprofen, flurbiprofen, fluoxetine, gabapentin, ketoprofen, metoprolol, nadolol, naproxen, nimodipine, verapamil and Botulinum A.[14] Additionally, most antidepressants (tricyclic, SSRIs and others such as Bupropion) are listed as "clinically efficacious based on consensus of experience" without scientific support.[14] Many of these drugs may give rise to undesirable side-effects, or may be efficacious in treating comorbid conditions, such as depression.
Other drugs:
50 mg or 75 mg/day of butterbur (Petasites hybridus) rhizome extract was shown in a controlled trial to provide 50% or more reduction in the number of migraines to 68% of participants in the 75 mg dose group, 56% in the 50 mg dose group and 49% in the placebo group after four months. Native butterbur contains some carcinogenic compounds, but a purified version, Petadolex, does not.[15]
Cannabis was a standard treatment for migraines from 1874 to 1942.[16] It has been reported to help people through an attack by relieving the nausea and dulling the head pain, as well as possibly preventing the headache completely when used as soon as possible after the onset of pre-migraine symptoms, such as aura.[16]
Supplementation of coenzyme Q10 has been found to have a beneficial effect on the condition of some sufferers of migraines. In an open-label trial,[17] Young and Silberstein found that 61.3% of patients treated with 100 mg/day had a greater than 50% reduction in number of days with migraine, making it more effective than most prescription prophylactics. Fewer than 1% reported any side effects. A double-blind placebo-controlled trial has also found positive results.[18]
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy believed to reduce the frequency of migraine attacks. A number of clinical trials have been carried out to test this claim, but a 2004 review article concluded that the results have been contradictory and inconclusive.[19] However, since then, more studies have been carried out.[20] As well as its prophylactic properties, feverfew is also touted as a migraine abortative.
Magnesium citrate has reduced the frequency of migraine in an experiment in which the magnesium citrate group received 600 mg per day oral of trimagnesium dicitrate. In weeks 9–12, the frequency of attacks was reduced by 41.6% in the magnesium citrate group and by 15.8% in the placebo group.[21]
Omega 3 fatty acids have been studied as a method of controlling frequency and intensity of migraines, with a Danish study showing 2/3 of participants who took Omega 3 supplements seeing a decline in intensity and duration of migraines of roughly 30%[22], however another study found Omega 3 treatment to be non-effective[23]
The supplement Riboflavin (also called Vitamin B2) has been shown (in a placebo-controlled trial)[24] to reduce the number of migraines, when taken at the high dose of 400 mg daily for three months.[25][26]
There is tentative evidence that Vitamin B12 may be effective in preventing migraines.[25] In particular, in an open-label pilot study, 1 mg of intranasal hydroxocobalamin (a form of Vitamin B12), taken daily for three months, was shown to reduce migraine frequency by 50% or more in 10 of 19 participants.[27] Although the study was not placebo-controlled, this response is larger than the typical placebo effect in migraine prophylaxis.[4]
Melatonin has been studied in migraine and other headache disorders. In an open label study, migraine patients taking melatonin 3 mg before bedtime with a good headache response and tolerability. Melatonin has multiple mechanisms affecting migraine pathophysiology.[28]
Surgical options for reducing or preventing migraines is an active area of research. Treatment of chronic migraines with botulinum neurotoxin (Botox) injections appears to be effective, but the Botox injections do not appear to work for episodic migraines.[29] Several invasive surgical procedures are currently under investigation. One involves the surgical removal of specific muscles or the transection of specific cranial nerve branches in the area of one or more of four identified trigger points.[30] There also appears to be a causal link between the presence of a patent foramen ovale and migraines.[31][32]
Transcranial Magnetic Stimulation (TMS): At the 49th Annual meeting of the American Headache Society in June 2006, scientists from Ohio State University Medical Center presented medical research on 47 candidates that demonstrated that TMS — a medically non-invasive technology for treating depression, obsessive compulsive disorder and tinnitus, among other ailments — helped to prevent and even reduce the severity of migraines among its patients. This treatment essentially disrupts the aura phase of migraines before patients develop full-blown migraines.[33] In about 74% of the migraine headaches, TMS was found to eliminate or reduce nausea and sensitivity to noise and light.[2] Their research suggests that there is a strong neurological component to migraines. A larger study will be conducted soon to better assess TMS's complete effectiveness.[34] In June 2008, a hand-held apparatus designed to apply TMS as a preemptive therapy to avert a migraine attack at the onset of the aura phase was introduced in California.[35]
Biofeedback has been used successfully by some to control migraine symptoms through training and practice.[36]
Hyperbaric oxygen therapy has been used successfully in treating migraines.[37][38][39] This suggests that sufferers might be treated during an attack with a hyperbaric chamber of some sort, such as a Gamow bag (as is done in the treatment of "The Bends" and altitude sickness).
Bruxism, clenching or grinding of teeth, especially at night, is a trigger for many migraineurs. A device called a nociceptive trigeminal inhibitor (NTI) takes advantage of a reflex limiting the force of clenching. It can be fitted by dentists and clips over the front teeth at night, preventing contact between the back teeth. It has a success rate similar to butterbur and co-enzyme Q10, although it has not been subjected to the same rigorous testing as the supplements. Massage therapy of the jaw area can also reduce such pain.
There is a speculative connection between vision correction (particular with prism eyeglasses) and migraines. Two British studies, one from 1934[40] and another from 1956[41] claimed that many patients were provided with complete relief from migraine symptoms with proper eyeglass prescriptions, which included prescribed prism. However, both studies are subject to criticism because of sample bias, sample size, and the lack of a control group. A more recent study[42] found that precision tinted lenses may be an effective migraine treatment. (Most optometrists avoid prescribing prism because, when incorrectly prescribed, it can cause headaches.)
Many physicians believe that exercise for 15–20 minutes per day is helpful for reducing the frequency of migraines.[43]
Sleep is often a good solution if a migraine is not so severe as to prevent it, as when a person awakes the symptoms will have most likely subsided.
Diet, visualization, and self-hypnosis are also alternative treatments and prevention approaches.
Sexual activity has been reported by a proportion of male and female migraine sufferers to relieve migraine pain significantly in some cases.[44]
In many cases where a migraine follows a particular cycle, attempting to interrupt the cycle may prolong the symptoms. Letting a headache "run its course" by not using painkillers can sometimes decrease the length of an episode. This is especially true of cases where vomiting is common, as often the headache will subside immediately after vomiting. Curbing the pain may delay vomiting, and prolong the headache.
A number of forms of alternative medicine, particularly bodywork, are used in preventing migraines.
Clinical trials have suggested that chiropractic care may be an efficacious treatment for migraine headaches[45][46] Likewise, Massage therapy, physical therapy, and Bowen Technique[47] are often very effective forms of treatment to reduce the frequency and intensity of migraines. These initial studies are limited by lack of control subjects, poor control subjects, lack of blind study design, small sample sizes, and other methodological flaws.[48] Chiropractic researchers have argued that the current evidence for chiropractic treatment of migraines indicates that "evidence is steadily increasing to the point where there is now seen to be a moderate level of efficacy for chiropractic SMT in the treatment of headaches or migraines".[48] The effect of chiropractic treatment may be mediated by stress release,[48] and may be more efficacious for tension-type headaches than migraines[49] A review of the literature until 2004 found that "Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. ... In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy."[49]
Frequent migraines can leave the sufferer with a stiff neck which can cause stress headaches that can then exacerbate the migraines. Claims have been made that Myofascial Release can relieve this tension and in doing so reduce or eliminate the stress headache element.
Some migraine sufferers find relief through acupuncture, which is usually used to help prevent headaches from developing.[50] Sometimes acupuncture is used to relieve the pain of an active migraine headache.[51] In one controlled trial of acupuncture with a sham control in migraine, the acupuncture was not more effective than the sham acupuncture but was more effective than delayed acupuncture.
Additionally acupressure is used by some for relief. For instance pressure between the thumbs and index finger to help subside headaches if the headache or migraine isn't too severe.
Incense and scents are shown to help. The smell and incense of peppermint and lavender have been proven to help with migraines and headaches more so than most other scents.[52] However, some scents can be a trigger factor.
Large anecdotal evidence suggests that serotonergic psychedelic drugs such as LSD or psilocybin can prevent migraine headaches.
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