A primer on migraine headaches

Migraine headache is a common, disabling condition. When migraine headaches become frequent, therapy can be challenging. Preventative therapy for migraines remains one of the more difficult aspects, as while there are valid randomized controlled trials to aid decision making, no drug is completely effective, and most have side effects.

Medications used for migraine can be divided into two broad categories: symptomatic or acute medications to treat individual migraine attacks, or preventative medications which are used to reduce headache frequency. Symptomatic migraine therapy alone, although helpful for many patients, is not adequate treatment for all. Patients with frequent migraine attacks may still have pain despite treating symptoms, and when symptomatic medications are used too often, they can increase headache frequency and may lead to medication overuse headache.

Physicians need to educate patients about migraine triggers and lifestyle factors. Common headache triggers include caffeine withdrawal, alcohol, sunlight, menstruation and changes in barometric pressure. Lifestyle factors such as stress, erratic sleep and work schedules, skipping meals, and obesity are associated with increased migraine attacks.

Overuse of symptomatic headache medications is considered by headache specialists to make migraine therapy less effective, and stopping medication overuse is recommended to improve the chance of success when initiating physician prescribed therapy.

When preventative therapy is initiated, 1 of 3 outcomes can be anticipated. Patients may show improvement, with 50% or more a reduction in headache frequency which can be assessed using a headache diary. People may develop side effects such as nausea or weight gain, or the drug may be ineffective in some individuals.

An adequate trial of medication takes 8 to 12 weeks, and more than one medication may need to be tried. There is little evidence about how long successful migraine treatment should be continued but recent studies suggest that most patients relapse to some extent after stopping medication.