Migraines are a complex entity and often there is not a single cause or trigger for migraines rather there is a combination of genetic and environmental factors that contribute to an individual’s propensity to develop migraines. For this reason, I believe it is important to develop a multifactorial approach to diminish migraine frequency and intensity.
There are 4 basic steps:
Migraines thrive on fluctuations in your life. The goals of these lifestyle changes are to minimize these fluctuations. Routine, Routine, Routine.
Sleep: It is best to go to sleep at the same time every night and wake up at the same time every morning whether it is a weekend or weeknight. Both too much sleep and too little sleep can be a trigger for migraine.
Exercise: It is important not to be overly ambitious and to set daily obtainable goals (check with your doctor before initiating a new exercise routine). I recommend walking. Walking not only can result in weight loss, reduction of blood pressure and cholesterol levels, as part of a daily routine it can help reduce migraines.
I recommended 30 minutes per day whether it is rain, snow or shine. Sometimes it is difficult to incorporate walking into a busy day, I suggest getting off the bus stop early or parking further way from work. There are numerous other exercise options including running, yoga, biking and spinning.
Stress: Ideally we would all like to lead stress free lives but realistically this is just not possible. However learning to cope with stress is a possibility. There are number of approaches including journaling, walking, meditation, yoga, and biofeedback.
When it comes to diet, it is not only what you eat that is important but also how you eat. Rather than eating a couple of meals per day or only when you’re hungry, plan to have small frequent light meals every four hours. Some of the common foods known to trigger migraine include citrus, dairy, alcohol, aspartame, MSG and nitrates. Avoids processed foods and meats, which often contain migraine triggers.
Caffeine: I love it; you love it but is it really worth the headache? Caffeine can be effective in helping to abort a migraine episode but caffeine taken on a daily basis can contribute to frequent migraines. Kick the habit; consider herb tea.
There are a number of supplements and herbs which have been demonstrated to be helpful in migraine prevention however similar to prescription drugs, these supplements can have side effects and interact with other medications (see below). It is recommended that women who are pregnant or breast feeding should not take supplements or herbs.
Based on reviews of clinical trials the following supplements (and doses) have been given a strong recommendation in the guidelines provided by the Canadian Headache Society (1).
Butterbur (petasites hybridus root extract) 75 mg twice a day. Only commercially prepared products in which plant carcinogens and hepatotoxic alkaloids have been removed and which have been standardized to contain a minimum of 15% petasins are recommended. Patients should be cautioned against consuming the plant in any other form.
Riboflavin (vitamin B2) 400 mg/day . This supplement can interact with some medications, including tricyclic antidepressants, anticholinergenic drugs, phenobarbital and probenecid.
Coenzyme Q10 100 mg three times a day. CoQ10 can interact with several medications including blood thinners such as warfarin (Coumadin), some cancer medications, and medications for high blood pressure.
Magnesium citrate 600 mg/day . Side effects of magnesium include diarrhea. Magnesium can interact with medications including heart medications, diuretics (water pills), some antibiotics, and muscle relaxants.
Medications can be divided into 2 general categories, Acute Abortive Therapies and Prophylactic Therapies. Acute therapies are used to abort or stop a headache once the pain has begun. Prophylactic therapies are used to prevent or reduce migraine frequency.
Acute Abortive Therapy
Even if you do take the recommended lifestyle, dietary and supplement steps, you will still likely experience some migraines and it is important to have an approach so you can abort the migraine as quickly as possible.
If possible remove yourself from excessive stimuli and lie down in a dark, quiet, cool room.
The Key to aborting the headache is to take acute abortive medication as early in the headache course as possible (2). As an initial step, the Canadian Headache Society Guidelines recommend over-the-counter medications such as Ibuprofen, ASA, or acetaminophen (Tylenol) (2). These should not be taken if you are pregnant without discussion with your doctor. Prescription anti-inflammatories may include naproxen sodium and diclonfenac potassium.
The migraine specific medication may be prescribed at your consultation. These typically include one of the triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan (2).
Medication Overuse Headache
Medication Overuse Headache can occur if you are experiencing frequent migraine and taking opioids, combination analgesics, or triptans on ten days a month or more, or a simple analgesic (acetaminophen, ASA, NSAIDs) on 15 days a month or more (3). Patients in this situation need to be on a prophylactic (preventative medication) to reduce their migraine frequency and intake of acute abortive therapies.
The use of medication is not my first choice for migraine prevention however when diet/lifestyle and supplements do not significantly diminish the headache frequency, medication should be considered. There are numerous medications, which can effectively decrease headache frequency and intensity and the right option for you involves consideration of other medical conditions, potential side effects and lifestyle. These medications are listed below and may be discussed at your appointment.
Amitriptyline, Topiramate, Botox, Propranolol, Nadalol, Metoprolol, Gabapentin, Candesartan, Divalproex sodium, Flunarizine, Pizotifen, Venlafaxine, Verapamil, and Lisinopril.
1. Canadian Headache Society Guideline for Migraine prophylaxis:
Volume 39 Number 2 (Supplement 2) March 2012
2. Canadian Headache Society Guideline: acute drug therapy for migraine headache.
Worthington I, Pringsheim T, Gawel MJ, Gladstone J, Cooper P, Dilli E, Aube M, Leroux E, Becker WJ; Canadian Headache Society Acute Migraine Treatment Guideline Development Group.
Can J Neurol Sci. 2013 Sep;40(5 Suppl 3):S1-S80
3. IHS headache classification