Choosing the Right Preventive Treatment
What primary care practitioners should know about migraine prevention
Preventive treatments can give patients an opportunity to experience more pain-free days by limiting migraine attacks before they occur. There are a wide array of preventive treatments that can help patients reduce the frequency and intensity of their migraine attacks, and lessen the chance of overusing acute treatments. These range from oral medications to lifestyle modifications to nutraceuticals. Learn more about what to consider when prescribing preventive treatments for your patients.
Preventive Treatment Considerations
Who is a good candidate for preventive treatment?
Primary care practitioners should analyze a patient’s headache history to determine if they experience episodic or chronic migraine. A patient meets diagnostic criteria for chronic migraine when they experience more than 15 headache days per month with at least eight that include migraine features for more than three months. Once physicians understand the status of the patient’s migraine, they should discuss treatment expectations.
Set realistic expectations
Setting realistic expectations regarding treatment goals puts the patient onto a path for success. Physicians should discuss goals in terms of a reduction in migraine frequency, severity and burden as opposed to the complete elimination of migraine. For example, a realistic goal is to aim for a 50 percent reduction in migraine frequency during a specific timeframe.
What do preventive treatments entail?
When prescribing preventive treatments, it may be best to give each treatment an adequate trial for at least two months at goal dose, emphasizing that improvement is often gradual. As with all treatments, consider options that have the highest level of evidence-based efficacy. In addition to this, physicians should consider comorbidities and choose medications that treat coexisting disorders when possible.
Primary care practitioners should educate all patients on how lifestyle modifications can aid in their preventive care strategy. Because fluctuations in a patient’s daily routine can trigger migraine attacks, people with migraine are likely to see improvements if they maintain a routine bedtime and wake up time, eat regular and routine meals daily and perform moderate-intensity aerobic exercise daily.
Certain supplements have been shown to aid in migraine prevention including magnesium, riboflavin, coenzyme-Q10 and melatonin. Physicians should weigh common side effects and contraindications and consider combining nutraceuticals with prescription preventives before making a recommendation.
Preventive prescription medications for migraine are offered in many forms such as tablets, nasal sprays and injections. Medication classes used to prevent migraine include antiepileptics, antidepressants, antihypertensives, onabotulinumtoxin-A and CGRP antibodies. Physicians should give thought to the common side effects, contraindications and who the medications should be considered for before prescribing.
Importance of Patient Care
Effective treatment for migraine prevention requires that physicians establish a therapeutic relationship with their patients. Physicians should work to understand patient goals for treatment as well as if they have any preferences for treatment modalities such as more natural approaches or prescription medications. Patients should be made aware of the side effect profiles of preventive medications and learn about adherence and compliance to dosing frequency. Finally, physicians should consider the cost of treatment options and any insurance restrictions to deliver the best care to their patients.
Primary care practitioners are essential to identifying and treating headache disorders. The American Headache Society’s First Contact — Headache in Primary Care program provides educational resources to empower healthcare professionals and improve headache and migraine care. Learn more about the program here.