Module II

Prevention of Migraine

The goal of Migraine preventive therapy is to reduce the frequency of migraine attacks, days with Migraine and headache, severity of symptoms,frequency of taking acute migraine therapy and migraine related disability. However, in a clinical setting, the measure of success and failure are often more subjective and individualized according to the specific patient.

Lifestyle Modification and Trigger Avoidance

Generally, it is believed that changes or fluctuations in a person’s usual daily routine can trigger migraine attacks. Thus, individuals with migraines are likely to do better if they maintain a stable daily schedule that includes going to sleep at the same time each night, waking at the same time each day, regular meals, exercising and maintaining a consistently low stress lifestyle.

Several studies and systemic review of literature has concluded that aerobic exercise can provide benefit to the headache pattern.

Maintenance of a daily headache diary is recommended to obtain an accounting of migraine frequency, treatment pattern and potential migraine attack triggers. Commonly cited triggers include high stress, stress let down (moving from a high stress to a low stress environment, such as might occur during a vacation), weather changes, sex hormone fluctuations in women, not eating, alcohol, sleep disturbances,odours, light, smoke, heat and certain foods.

Foods that are commonly cited as triggers include those with mono sodium glutamate, those with nitrates/nitrites (processed meat), aged cheese and artificial sweetness. Caffeine overuse and caffeine withdrawal are both associated with headache and migraine.

Risks factors for Migraine

Include: -

1.     Obesity

2.     Sleep disturbances

3.     Excessive caffeine intake

4.     Psychiatric disease

5.     Higher baseline headache frequency

6.     The Frequent use of abortive migraine medications

7.     Females

8.     Lower socio-economic status

9.     Co-morbid pain disorders

10. Major life events

11. History of head and neck injury

12. Ineffective acute treatment of migraine attack

It is presumed that avoiding these risks factors when possible reduces the risk of developing more frequent headaches. Among these risk factors, caffeine, obesity, certain sleep disorder and medication over use are avoidable or modifiable.

Caffeine

Caffeine cessation among frequent users will improve migraine burden for certain individuals. Thus, a period of caffeine cessation lasting at least two to three months is recommended for certain individuals with frequent migraines. Individuals with regular intake of large amounts of caffeine should slowly taper their caffeine intake to avoid an initial headache exacerbation due to caffeine withdrawal.

Over use of Acute Headache Medications

Medication overuse refers to taking migraine abortive medication too frequently. Simple analgesics are overused if taken on 15 or more days per month,whereas more strong medications are overused 10 days per month.

Sleep

Poor sleep and sleep disturbances are positively associated with the occurrence and frequency of migraine attacks.

Obesity

Obesity is associated with a moderately higher risk of migraine and with an increasing number of headache days among those with migraine.

Migraine Preventive Treatments

Drugs

Most medications accurately used for the prevention of migraine were developed for the purpose of treatment of epilepsy, hypertension and depression.

Preventive medications should be given when migraine attacks are frequent (four or more attack per month) or 8 headache days per month. Such medication should also be considered for individuals whose attacks substantially interfere with their quality of life despite use of acute medications and life style modification strategies or if contra-indicatons, treatment resistance or adverse events preclude the use of effective acute medications.

The adherence to preventive medication is poor even among individuals with chronic migraine.

Neuro stimulation

Several modalities of invasive and non invasive neuro stimulation have been studied or are currently being studied for prevention of migraine. These devices are used on a daily basis for the prevention of migraine.       

Pharmacologic Therapy

Special consideration for behavioural Therapy is given when the patient prefers non-Pharmacologic Therapy and when the patient’s behaviour and stress are triggers for often migraine attacks or add significantly to migraine-related disability. Furthermore, combining pharmacologic treatment with behavioural therapy is likely to provide greater benefits than other therapy alone.

Treatment of Acute Migraine

In spite of a number of advances in diagnosis and treatment , only 22% of patients with Migraine use migraine specific medications and a nearly equivalent percentage on other analgesics for their attacks. This is especially important as inadequate acute treatment exerts a significant socioeconomic burden and has also been associated with transition from episode to chronic migraine.

Treatment approaches frequently follow one of these models of case including step care across attacks,step care within attacks and stratified care.

In step care within attacks, the patient initiates treatment with low-cost care, non-specific, analgesic medication and if unsuccessful, can advice themselves after several hours to more migraine-specific treatment options along a step wise pattern within an individual attack.

In stratified care, the patient is entrusted with determining which attack will respond to various treatments and is given the autonomy to make the appropriate treatment decision based on his or her personal experience and preference inspite of a growing armamentarium of treatment options for migraine. Many patients remain unsatisfied with their acute medication. A comprehensive treatment plan for every patient with migraine should include an individualized evidence-based approach to acute treatment.

Prognosis

The long-term prognosis of migraine varies considerably between individuals. Outcomes ranges from complete or partial clinical remission to decades of attack that do not change in frequency severity or symptom profile, or to development of chronic migraine.

Conclusion

Migraine is a disease associated with significant psycho social impact. The diagnosis of migraine requires a good clinical history and exclusion of other causes of headache. However future investigations are needed when the findings from the history and clinical examination are atypical of migraine or if there is a recent change in the character of the patient’s headache. Current pharmaceutical migraine treatments have revolutionized migraine management. Optimal treatment used to be individualized taking into consideration the side effects of medication, duration and severity of symptoms and the outcome of previous treatments.