General measures in the management of migraine

Some general steps in the management of migraine include:

• identifying and avoiding trigger factors which can reduce the frequency of migraine attacks by up to 50% (1)
• regular sleep and dietary measures:
  • sleep can aid recovery
  • keep regular mealtimes
  • avoidance of trigger factors
    • when migraine attacks are frequent, a trigger diary may be useful in addition to a diary detailing attacks
    • a patient can be given a list of common triggers and record those present each day whether they have a migraine attack or not
    • the daily trigger diary and attack diary are best reviewed after at least five attacks. The information in each is compared for coincidence of (multiple) triggers with attacks
    • examples of possible trigger factors include (2):
      • extremes of weather (e.g. very hot or cold, strong winds)
      • long distance travel
      • loud noise or bright lights missing meals
      • strenuous unaccustomed exercise
      • too much or too little sleep
      • emotional stress and anxiety
      • in about 20% a foodstuff may be a trigger factor for migraine (2)
        • dietary triggers, if real, become obvious to patients and are usefully avoided
        • a suspected food should be excluded for a few weeks - when many foods are suspect, supervision by a dietician is advisable as elimination diets can result in malnutrition. Excluded foods should be reintroduced if there is no significant improvement. There is no case for blanket avoidance of cheese, chocolate or other foods, nor for other dietary manipulation
          
          
• preventative treatment - general principles (3)
  • prescribing decisions should be made with reference to the patient’s current clinical situation and their future plans (e.g. pregnancy or contraception)
  • preventive treatment should be offered as an option to patients with 4 or more migraine days a month as this frequency is associated with significant disability
    • such an approach will also mitigate the risk of escalation of acute treatment and consequent development of medication overuse headache
  • acute treatment on more than 2 days per week is associated with medication overuse, which renders preventive treatment less effective
  • preventive medications must be titrated slowly to an effective or maximum tolerable dose and continued for at least 6-8 weeks to adequately assess effect
  • a headache diary may help evaluate response to treatment
  • consider gradual withdrawal after 6-12 months of effective preventive
  • monitor quality of life through validated tools such as HIT-6. The HIT-6 score can be downloaded

Reference:

1. Prescriber 2002; 13(20).
2. British Association for the Study of Headache (BASH) guidelines 2004
3. British Association for the Study of Headache (BASH) guidelines 2019