Clinical Pearls on Migraine Prevention

Stephanie J. Nahas, MD, FAHS, MSEd explains how migraine prevention and patient education go hand in hand.

For those living with migraine attacks that are frequent, disabling or long-lasting, preventative measures are especially beneficial. While 40% of those patients could see improved outcomes, only 15% of patients receive preventive options. While it’s not uncommon for patients to get discouraged while they seek effective options, finding the right preventive regimen could dramatically improve a patient’s quality of life.

Dr. Stephanie Nahas, the Director of the Headache Medicine Fellowship Program and Assistant Director of the Neurology Residency Program at Thomas Jefferson University, recently spoke with AHS about the importance of educating patients on migraine prevention.

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The term “migraine prevention” in and of itself can set up unrealistic expectations. There is no cure for migraine, and becoming fully headache-free is not attainable for the vast majority of patients. So how do you communicate hope to patients?

Dr. Nahas recommends moving forward one step at a time.

“What I do guarantee people is that we won’t give up until we make you at least somewhat better, and we’ll set goals incrementally,” says Dr. Nahas. “Once we hit a goal, we’ll set the next goal, and we keep setting the bar higher and higher.”

Pursuing preventive treatment often requires multiple long-term investments in prospective solutions, which can be frustrating for any patient, especially if their migraine attacks are frequent or disabling. Set them up for success by outlining timelines for results.

“As a general rule for most preventive treatments, we say two to three months,” Dr. Nahas says, adding, “Within six to eight weeks you should start to see improvement, but we start at a low dose for many preventive medications. Maybe 10% to 25% of the target dose, and it may take several weeks to reach that target dose. So, really the clock starts when the target dose is hit, and then you’ve got to give it at least several weeks, if not a couple of months.”

A personalized treatment plan can make all of the difference. “For somebody who has ten or fewer migraine attacks each month, they should be treated right away, at the very first sign,” she says. “For somebody who is limited on how many pills of a certain medication they can have per month, you may have to pick and choose which ones you treat with your most effective option.”

There are also several non-pharmacological ways to treat a migraine attack preemptively, such as by retreating to a quieter or darker room, or canceling any strenuous activities that had been scheduled for that day.

“When people think about prevention they often first think of drugs, but that’s not where I like to start the conversation. I like to start with healthy lifestyle changes and other things that a patient can do for themselves without having to take any extra medicine,” Dr. Nahas says.

But ultimately, routine and predictability are key. “We like to say that the migraine brain is sensitive. It doesn’t like change, it doesn’t like surprises,” Dr. Nahas says. That means keeping regular sleep times, regular meal times and a regular exercise routine. Other evidence-based options include a healthier diet, practicing meditation and yoga and biofeedback.

All of these suggestions have something in common: empowering patients. “It’s chaotic when an attack may hit them from, from any time, any, any day out of left field, and so patients feel powerless,” says Dr. Nahas. “Moving that locus of control to within, to things that they can modify and can stay in control of, that will then secondarily lead to better control of migraine itself.”

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