Migraine Prevention Guide

Should You Be on Migraine Prevention?

Most migraine sufferers treat an active attack once it has already started, by using painkillers or triptans.

For those who experience frequent migraines, it may be more appropriate to consider preventative treatment, stopping the attack from occurring in the first place.

Responding well to prevention treatment may even reduce the frequency and severity of your migraine by 30 to 50%

Should you be on migraine treatment?

If you experience migraines rarely, or these are typically managed well through avoiding triggers or over-the-counter painkillers, then you may not need preventative treatment. If however, one of the following applies, then preventative treatment is recommended:

• Experiencing migraines on 4 or more days per month.

• Do not respond to or have side effects with triptans or painkillers - around 30% of migraine patients do not respond to triptans

• Have cardiovascular conditions making it unsafe to use triptans

• Have chronic migraines or difficult to treat migraines

• Need treatment for menstrual migraines

• Have hemiplegic migraines

• Frequently using painkillers or triptans

• You experience prolonged or disabling migraine attacks

Prevention isn’t just about reducing headaches. This treatment can also reduce associated migraine symptoms such as:

• Nausea

• Brain fog

• Light sensitivity

• Fatigue after attacks

If two or more of the following applies to you, you may benefit from preventative treatment:

• 4 or more migraine days per month

• Migraines lasting longer than 24 hours

• Migraines affecting day-to-day life, such as work or social activities

• Migraines not responding effectively to triptans or painkillers

• Using migraine medication more than 10 days per month.

First-Line Preventive Medications

There are several treatments available with strong evidence for migraine prevention. Although some were developed for other conditions, they now have a key role and are widely used for migraine prevention.

Propranolol

The most common migraine prevention treatment is propranolol. This works by calming the nervous system and stabilising blood vessels in the brain.

The starting dose is 40mg, taken two to three times daily. The dose is gradually increased based on response up to 240mg per day.

Whilst some may notice improvements in a few weeks, it can take up to 12 weeks for therapeutic benefits to become apparent.

Common side effects include:

• Fatigue

• Dizziness

• Cold hands or feet

• Sleep disturbance

• Diarrhoea

For a complete list of side effects, please see the patient information leaflet.

Whilst effective, propranolol should not be taken by and is contraindicated in:

• Anyone allergic to propranolol or any of the other ingredients

• Anyone with asthma or lung disease

• You are pregnant, trying to get pregnant or are breastfeeding

• You have a slow heart rate (bradycardia)

• You have severe circulation problems in your limbs

Amitriptyline

Amitriptyline has shown benefit in migraine prevention and may be more effective than propranolol in mixed migraine/tension headaches.

Originally an antidepressant, the dose for preventing a migraine is 10-25mg, usually in the evening. The dose can be increased up to 75mg daily.

Amitriptyline can help to prevent migraines and reduce their frequency, severity and duration.

Common side effects include:

• Constipation

• Dry mouth

• Fatigue

• Nausea

• Weight changes

• Sleepiness - usually taken at bedtime

For a complete list of side effects, please see the patient information leaflet.

Topiramate

Topiramate is an enti-epileptic medication which has strong evidence for the use in migraine prevention.

This works by reducing the bursts of electrical activity in your brain, restoring the normal balance of nerve activity.

The starting dose is 25mg daily, gradually increased to a maximum of 50-100mg per day. Improvement is usually seen in 4-12 weeks.

Topiramate must not be used in pregnancy as it can cause birth defects and developmental disorders in the foetus. Women of childbearing age must follow a pregnancy prevention programme.

Common side effects include:

• Constipation

• Sleep disorders

• Skin reactions

• Dry mouth

• Weight changes

For a complete list of side effects, please see the patient information leaflet.

Sodium valproate

Sodium valproate is also effective for migraine prevention but has safety restrictions.

Due to the high risk of birth defects and developmental problems, sodium valproate must not be used in women of childbearing potential unless no other treatment is effective. Due to this, sodium valproate is rarely prescribed for the prevention of migraine.

Common side effects include:

• Nausea

• Dizziness

• Vomiting

• Abdominal pain

• Diarrhoea

• Double vision

• Weight changes

For a complete list of side effects, please see the patient information leaflet.

Second-Line: CGRP Treatments for Prevention

When first-line treatments fail, specialists may recommend newer treatments which target the CGRP pathway.

CGRP plays a major role in migraine attacks by causing inflammation and pain signalling in the brain.

Two main classes of medicines target this pathway, CGRP monoclonal antibodies and the -gepants.

CGRP Monoclonal Antibodies

CGRP monoclonal antibodies were the first treatments specifically designed for migraine prevention. These treatments block the CGRP chemical, helping relieve symptoms.

Most CGRP antibodies are administered as injections either monthly or every 3 months include:

• Erenumab ( Aimovig)

• Fremanezumab (Ajovy)

• Galcanezumab (Emgality)

The only exception is Eptinezumab (Vyepti), which is given into a vein by infusion. This is administered in hospital once every 3 months.

These need to be prescribed by a specialist and are usually reserved for migraines that are frequent or difficult to treat.

Monoclonal antibodies may prescribed for you by your GP if:

1. You have at least 4 migraine attacks per month AND

2. You have tried 3 or more preventative medicines at the maximum doses you can tolerate for several months each, and they haven't worked.

These treatments half the number of migraine days, and have been shown to work in those patients where other preventative treatments have failed.

The monoclonal antibodies are generally well tolerated though some may experience mild side effects. Crucially, they have fewer side effects compared to other preventative treatments.

The most common side effects include:

• Fatigue

• Injection site reactions

• Constipation

• Itching

Monoclonal antibody treatments must not be taken by and are contraindicated in:

• Pregnancy and breastfeeding

• Recent heart attack/stroke

• Raynaud’s syndrome

Gepants

Gepants, also known as CGRP antagonists block CGRP receptors and prevent migraines from occurring. These can be used both as preventatives and to treat an active attack.

The two gepant drugs available in the UK are:

• Rimegepant (Vydura)

• Atogepant (Aquipta)

Whilst these are available on the NHS, they are usually restricted to patients who have tried other treatments and failed, or who cannot tolerate other treatments.

Gepants are effective and have a dual action; they can treat migraines but also prevent them. Benefits compared to other treatments are highlighted below:

Gepants are much better tolerated compared to other treatments. With a side effect profile similar to placebo, the main side effect patients experience is nausea.

Non-Drug Prevention Strategies

Non-drug strategies are crucial for reducing the frequency and intensity of migraines. Clinical data suggests lifestyle modifications can improve pain modulation.

Identifying triggers and taking manageable steps to avoid them can play a significant role in improving the outcome of your migraines.

Whilst many patients believe a certain food triggers their migraine, modern research suggests these are actually early symptoms of the migraine itself.

• The myth - chocolate or red wine are universal triggers

• Reality - the environment, bright lights, noise are more consistent triggers.

Other common triggers to address include

• Irregular sleep

• Dehydration

• Hormonal changes

• Stress

• Missed meals

Improve sleep regularity

Sleep disruption is one of the strongest migraine triggers and is a primary cause of migraines becoming chronic. Sleep deprivation affects the brain's ability to regulate pain so it's important to improve sleep quality.

Implementing the following techniques may help:

• Avoid screens before bedtime

• Limiting caffeine in the afternoon

• Relax, unwind, and try meditation to help you sleep

• Create the right sleep environment

• Maintain a consistent sleep schedule

Dietary patterns

Skipping meals or irregular meals can fluctuate blood sugar levels, acting as a major trigger to migraines.

Caffeine, when consumed excessively or irregularly is also well-documented to cause migraines.

Magnesium

Magnesium supplements are recommended as a preventative measure as it plays a role in regulating neurone activity.

Daily, high dose magnesium has been shown to decrease the frequency of migraine attacks, though more research is needed.

Riboflavin (vitamin B2)

High doses of vitamin B2, (400mg daily) has been shown to reduce the frequency of migraine attacks and headache days.

Research has shown it is highly effective and tolerated well.

Exercise

Regular exercise can help reduce migraine frequency whilst improving overall general health. It can do this by helping manage stress, improve sleep and improve overall wellbeing.

Studies have shown that regular exercise can:

• Reduce frequency of migraine attacks

• Reduce how long migraine attacks last

• Reduce migraine severity.

Whilst beneficial, regular exercise can be difficult for some:

• Exercise may itself be a migraine trigger

• Physical activity may worsen symptoms

• Vestibular migraine - leads to dizziness and vertigo, making it difficult to exercise

The type of exercise best suited for migraine sufferers are:

• Aerobic exercise - brisk walking, jogging or cycling which increases your heart and breathing rate.

• Muscle strengthening/ resistance exercise - including lifting weights, yoga and pilates.

• Relaxation exercise and techniques - yoga, progressive muscle relaxation and breathing exercises- help to reduce muscle tension and manage stress.

Stress management

Stress is a common migraine trigger. Here are some tips for managing stress with migraine:

• Pace yourself - take the time to rest properly and recover from a migraine attack. It may be tempting to try and ‘catch up’ on tasks when you have a good day but this may mean you are overdoing things.

• Make time for yourself - spending time on things you enjoy can distract you from ongoing feelings of stress.

• Be flexible in your plans - Don't be afraid to adapt or change your goals and ask for support when you need it.

• Know your migraine - keeping a headache diary can help you spot possible triggers and any patterns to your migraine attacks.

How Long Does Migraine Prevention Take to Work?

Starting a migraine prevention plan takes time. Unlike acute treatments which work within hours, it can take time for the brain to adjust to preventative treatment.

The British Association for the Study of Headaches (BASH) states to review a preventative treatment's success not before 3 months of reaching the target dose.

Getting Migraine Prevention on the NHS

Accessing migraine treatment on the NHS follows a stepped pathway.

Step 1: GP appointment

If you experience four or more migraine days per month, your GP may prescribe a first-line preventative medication such as:

• Propranolol

• Topiramate

• Amitriptyline

Before escalation to a specialist treatment via neurologist referral, you are expected to try at least 2 of these treatments for 12 weeks each.

Step 2: Neurology referral

If first-line preventative treatments have failed, contraindicated or cause side effects, the next stage is a referral to neurology or specialist headache clinic.

Specialists can prescribe treatments like:

• CGRP monoclonal antibodies

• Gepants - like Vydura

To qualify for Vydura on the NHS, you must have tried 3 previous preventative treatments which failed. For this reason, many decide to start treatment from private providers such as Quick Meds.

What to bring to your GP appointment

To ensure you access tailored treatment quickly, you will need to evidence your migraines and the extent of their impact on your daily life. We advise taking with you:

• A headache diary - which clearly shows the number of migraine days

• Previous medication - a list of previous medication you have taken and why you stopped. (i.e. ineffective)

• Red flags - mention any aura symptoms or changes in headache patterns to aid the GP’s treatment plan