Migraine prevention: preventive medicines, lifestyle changes and when to see a specialist

Migraine is a condition with a typical pattern of symptoms: a throbbing headache, often on one side, with feeling or being sick and sensitivity to light and sound. The NHS says attacks usually last between 4 hours and 3 days, and some people have attacks several times a week while others have them far less often.

Treatment falls into two groups. Acute treatment is what you take during an attack to relieve symptoms, such as painkillers, triptans, gepants and anti-sickness medicines. Prevention is aimed at making attacks less frequent, less severe or both. It includes medicines taken regularly even when you are well, as well as lifestyle changes, acupuncture and psychological approaches.

Most people find their migraines slowly get better as they get older, according to the NHS, and in women migraine often improves after the menopause and sometimes in pregnancy. That does not make prevention less worthwhile, because attacks in the meantime can disrupt work, family life and sleep.

The NHS says to see a GP if your migraine attacks are severe or getting worse, last longer than usual, happen more than once a week, or are difficult to control, or if you regularly get migraine before or during your period. Those are the situations in which a preventive plan is typically discussed.

NICE does not set a rigid number of attacks for starting a preventive medicine. Its guideline instead asks the clinician to discuss benefits and risks with you and to take into account your preference, other health conditions, the risk of side effects and how much migraine affects your life. A person with a few severe, prolonged attacks may reasonably choose prevention, while someone with milder, occasional attacks may prefer to rely on acute treatment.

It is not known exactly what causes migraine, but the NHS says it happens when there are changes to nerves and blood vessels in the brain, and that you are more likely to have it if a close family member does. NHS inform says around half of people with migraine have a close relative with the condition.

Triggers differ from person to person and are not always obvious. The NHS lists having your period, anxiety and depression, stress and tiredness, skipping meals, too much caffeine and not getting enough regular exercise. NHS inform also mentions dehydration, hormonal changes, bright or flickering lights, strong smells, weather changes and some medicines, such as certain sleeping tablets, the combined contraceptive pill and hormone replacement therapy.

A headache diary helps to link attacks to triggers and also shows whether a treatment is working. NICE suggests considering a diary to record the frequency, duration and severity of headaches and to monitor how effective an intervention is. NHS inform suggests noting the date, time, what you were doing, how long the attack lasted, symptoms and any medicines you took, plus the start of your period if relevant.

The NHS suggests a GP may recommend lifestyle changes alongside any medicine. These are not a cure, but they remove some common triggers and support general health.

• Eat meals at regular times and avoid long gaps without food.

• Limit caffeine and alcohol, and stay well hydrated.

• Keep to a healthy weight and take regular exercise.

• Get plenty of sleep and keep a consistent sleep routine.

• Find ways to manage stress. The NHS lists relaxation techniques and cognitive behavioural therapy (CBT) among the preventive options.

The NHS names beta blockers, antidepressants and medicines for epilepsy as the main groups of medicines that help prevent migraine attacks. NICE guideline CG150 is more specific and says to consider propranolol, topiramate or amitriptyline after a full discussion. If the first one does not work or is not tolerated, a second option and then the remaining option can be tried, unless there are safety reasons not to.

Several safety points are built into the guidance. Topiramate should not be used for migraine prevention in pregnancy, or in women who could become pregnant, unless the conditions of the MHRA Pregnancy Prevention Programme are met, including highly effective contraception. For propranolol, NICE advises caution in people with depression and migraine because of the risk of harm from toxicity in overdose. For amitriptyline, prescribers are asked to take into account the advice on antidepressant withdrawal. NICE also says not to offer gabapentin for migraine prevention.

For people whose migraine has not responded to the usual preventive medicines, NICE technology appraisals recommend some newer treatments. CGRP inhibitors, including erenumab, fremanezumab, galcanezumab, eptinezumab and atogepant, are options for adults with at least 4 migraine days a month, only if at least 3 preventive medicines have not worked, are not tolerated or are unsuitable. Rimegepant is recommended for preventing episodic migraine in adults with at least 4 and fewer than 15 attacks per month under similar conditions. Botulinum toxin type A injections are an option for chronic migraine.

The guideline builds in review points: CGRP inhibitors should be stopped after 12 weeks if migraine frequency has not fallen by at least 50% in episodic migraine or at least 30% in chronic migraine, and botulinum toxin should be stopped if headache days have not reduced by at least 30% after two treatment cycles.

Taking acute painkillers too often can make headaches more frequent. The NHS advises trying not to take painkillers for more than 2 days a week, and NHS inform advises not taking painkillers on more than 10 days a month in the long term. If you find yourself needing pain relief that often, that is a good reason to ask about preventive treatment rather than simply continuing with painkillers.

Hormones matter for some people. NICE says combined hormonal contraceptives should not routinely be offered to women and girls who have migraine with aura, and NHS inform notes the small increase in the risk of ischaemic stroke with the combined pill. For predictable menstrual-related migraine that does not respond to standard acute treatment, NICE says frovatriptan or zolmitriptan taken on the days attacks are expected can be considered. If preventive treatment is needed during pregnancy, NICE says to seek specialist advice.

Prevention planning assumes the diagnosis of migraine is secure. The NHS says to call 999 for a headache that comes on suddenly and is extremely painful, problems speaking or remembering, loss of vision or blurred or double vision, drowsiness or confusion, a seizure, a very high temperature with signs of meningitis, weakness on one side of the body or face, or a recent head injury.

It also says to ask for an urgent GP appointment or call NHS 111 if an attack lasts longer than 72 hours, if aura symptoms last longer than an hour at a time, or if you are pregnant or have just had a baby. NICE adds that headache that is new or has a substantial change in character, or that is triggered by coughing, straining or exercise, should lead to consideration of further investigation or referral.

Most preventive treatment is started by a GP. The NHS says that if treatments do not help or are getting worse, you may be referred to a specialist, and NHS inform lists unclear diagnosis or poorly controlled significant migraine as reasons for referral to a neurologist. NICE does not recommend referring people for brain scans solely for reassurance when migraine has been diagnosed.

Some people choose a private neurologist for a quicker appointment or a second opinion. The medicines used for prevention are the same. The NICE appraisals for CGRP inhibitors and botulinum toxin set out when these newer options are recommended.