Chronic Migraine Prevention

If you experience frequent migraines, you know how they can disrupt your life. The good news is that a comprehensive prevention strategy can dramatically reduce both the frequency and severity of attacks. This guide will help you develop a personalized plan to take control of your migraines.

Understanding Chronic Migraine

What is Chronic Migraine?

Chronic migraine is defined as having 15 or more headache days per month, with at least 8 days having migraine features, for more than 3 months. This is different from episodic migraine (fewer than 15 days per month).

Migraine Phases

Understanding the phases can help you intervene early:

Prodrome (Hours to Days Before)

Mood changes (irritability, depression, euphoria)
Food cravings
Neck stiffness
Yawning
Increased urination
Sensitivity to light or sound

Aura (Minutes to an Hour Before)

Visual disturbances (flashing lights, zigzag lines, blind spots)
Sensory changes (tingling, numbness)
Speech difficulties
Not everyone experiences aura

Headache Phase (4-72 Hours)

Throbbing or pulsating pain (often one-sided)
Nausea and vomiting
Sensitivity to light, sound, and smell
Worsening with physical activity

Postdrome (Hours to Days After)

Exhaustion
Difficulty concentrating
Mood changes
Like a "migraine hangover"

The Value of Prevention

Prevention aims to:

Reduce frequency of migraine attacks
Decrease severity when migraines occur
Improve response to acute treatments
Reduce disability and improve quality of life
Prevent medication overuse headache

Identifying Your Triggers

Triggers are factors that can set off a migraine attack. Not everyone has the same triggers, and triggers may combine to produce an attack.

Keeping a Migraine Diary

Track the following for each migraine:

Date and time
Severity (1-10 scale)
Symptoms experienced
Potential triggers from the past 24-48 hours
Medications taken and their effectiveness
For women, where you are in your menstrual cycle

Use a paper diary, app, or digital tool consistently for at least 3 months.

Common Migraine Triggers

Hormonal

Menstrual cycle changes
Menopause
Hormonal contraceptives
Pregnancy

Dietary

Aged cheeses (tyramine)
Processed meats (nitrates/nitrites)
Alcohol, especially red wine
Chocolate
Caffeine (both too much and withdrawal)
MSG and artificial sweeteners
Skipping meals

Environmental

Weather changes (barometric pressure, temperature)
Bright or flickering lights
Strong smells (perfumes, chemicals)
Loud noises
Altitude changes

Sleep

Too little sleep
Too much sleep
Irregular sleep schedule
Sleep disorders (apnea)

Physical

Physical exertion
Head or neck trauma
Dental issues

Emotional

Stress (and letdown after stress)
Anxiety
Depression
Excitement

Trigger Management

Once you identify your triggers:

Avoidable Triggers

Certain foods and drinks
Strong smells
Flickering lights

Modifiable Triggers

Sleep schedule (make it regular)
Meal timing (don't skip)
Hydration (drink water throughout the day)
Stress (develop management strategies)

Unavoidable Triggers

Weather changes
Menstrual cycle
These require other prevention strategies

Preventive Medications

If lifestyle changes alone aren't enough, preventive medications may be recommended. These are taken regularly to reduce migraine frequency.

Who Should Consider Prevention?

Guidelines suggest prevention if you have:

4+ migraine days per month
Headaches that significantly impact your life
Poor response to acute treatments
Frequent use of acute medications (risk of medication overuse)
Certain migraine types (hemiplegic, brainstem aura)
Prolonged aura

Medication Categories

CGRP Inhibitors Newer medications targeting calcitonin gene-related peptide:

Monoclonal antibodies: Monthly or quarterly injections (aimovig, emgality, ajovy, vyepti)
Gepants: Oral medications (ubrogepant, rimegepant)
Often very effective with fewer side effects
Specifically designed for migraine

Anticonvulsants

Topiramate: FDA-approved, proven effectiveness
Divalproex: Also FDA-approved
Gabapentin: Sometimes used off-label
Side effects vary by medication

Antidepressants

Amitriptyline: Tricyclic, often effective
Venlafaxine: SNRI, may help
Can also help with comorbid depression/anxiety

Beta-Blockers

Propranolol, metoprolol, timolol
Originally blood pressure medications
Proven effectiveness for migraine

Other Options

CGRP inhibitors (newest class)
Botulinum toxin (Botox) for chronic migraine
Calcium channel blockers
ACE inhibitors

Working with Your Doctor

Start with a low dose and increase gradually
Give medications 2-3 months to assess effectiveness
Track your response carefully
Discuss side effects – adjustments may help
Combination therapy may be needed
Don't stop suddenly

Lifestyle Modifications

Lifestyle factors play a crucial role in migraine prevention.

Sleep Hygiene

Consistency is Key

Same bedtime and wake time daily (even weekends)
Aim for 7-9 hours of sleep
Create a restful environment

Sleep Environment

Cool, dark, quiet room
Comfortable mattress and pillows
Reserve bed for sleep (not screens)

Bedtime Routine

Wind-down period before bed
Avoid screens 1-2 hours before sleep
Relaxing activities (reading, gentle stretching)

Regular Exercise

Benefits:

Reduces stress
Improves sleep
Releases endorphins (natural pain relief)
May reduce migraine frequency

Guidelines:

Aim for 150 minutes of moderate exercise weekly
Start gradually if new to exercise
Stay hydrated
Warm up and cool down
Some find intense exercise can trigger migraines – find your balance

Dietary Strategies

Regular Meals

Don't skip meals
Eat at consistent times
Maintain stable blood sugar

Hydration

Drink water throughout the day
Aim for 8 glasses daily (more in heat/exercise)
Limit caffeine to moderate, consistent amounts

Magnesium-Rich Foods

Leafy greens
Nuts and seeds
Whole grains
Some evidence magnesium helps prevent migraines

Consider an Elimination Diet

Work with a dietitian
Systematically test trigger foods
Identify your personal triggers

Stress Management

Relaxation Techniques

Deep breathing exercises
Progressive muscle relaxation
Meditation and mindfulness
Guided imagery

Regular Stress Reduction

Daily relaxation practice
Regular exercise
Social connection
Hobbies and enjoyable activities

Cognitive Behavioral Therapy (CBT)

Proven effective for migraine
Helps change thought patterns
Develops coping strategies
Often covered by insurance

Screen and Environment

Reduce Eye Strain

20-20-20 rule: Every 20 minutes, look at something 20 feet away for 20 seconds
Adjust screen brightness
Consider blue light filtering
Proper lighting when reading

Manage Sensory Input

Sunglasses for bright light
Earplugs in noisy environments
Avoid strong fragrances if triggering

Acute Treatment Strategies

Even with prevention, you'll need acute treatments for breakthrough migraines.

Medication Options

Mild to Moderate

NSAIDs (ibuprofen, naproxen)
Acetaminophen
Combination analgesics

Moderate to Severe

Triptans (sumatriptan, rizatriptan, etc.) – first-line for many
Gepants (ubrogepant, rimegepant)
Ditans (lasmiditan)
Ergotamines (less commonly used now)

Adjuncts

Anti-nausea medications
Caffeine (in some combinations)

Timing Matters

Treat Early

Don't wait for pain to become severe
Best results when taken during early headache phase
Keep medications accessible

Avoid Overuse

Limit acute medication use to avoid medication overuse headache
Generally no more than 10-15 days per month
Discuss limits with your doctor

Non-Medication Acute Treatments

Rest

Dark, quiet room
Sleep if possible
Cold or warm compress

Hydration

Drink water
Electrolyte solutions if vomiting

Caffeine

May help some people
Can enhance pain reliever effectiveness
Be consistent to avoid withdrawal

Complementary Approaches

Supplements

Some evidence supports:

Magnesium: 400-600 mg daily
Riboflavin (Vitamin B2): 400 mg daily
Coenzyme Q10: 300 mg daily
Discuss with your doctor before starting

Acupuncture

Several studies show benefit for migraine prevention
May reduce frequency and severity
Consider trying a certified practitioner

Biofeedback

Learns to control body functions (heart rate, muscle tension)
Evidence supports effectiveness
Often combined with relaxation training

Massage and Physical Therapy

May help with neck tension and muscle triggers
Can reduce stress
Address any postural or musculoskeletal issues

Creating Your Prevention Plan

Step-by-Step Approach

Keep a Migraine Diary
- Track patterns for at least 3 months
- Identify triggers
Implement Lifestyle Changes
- Regular sleep schedule
- Consistent meals and hydration
- Exercise program
- Stress management
Consider Preventive Medication
- Discuss options with your doctor
- Choose based on your situation and comorbidities
- Give it time to work
Optimize Acute Treatment
- Have effective medications available
- Treat early
- Avoid overuse
Add Complementary Approaches
- Consider supplements
- Try acupuncture, biofeedback, or other approaches
- Find what works for you
Monitor and Adjust
- Continue tracking
- Adjust strategies based on response
- Maintain regular follow-up with your healthcare team

Setting Realistic Expectations

Prevention aims to reduce migraines, not necessarily eliminate them
A 50% reduction in frequency is considered a good response
Finding the right combination takes time
Be patient and persistent

When to Seek Help

Contact a healthcare provider if:

Your migraine pattern changes significantly
You have the "worst headache of your life"
Headaches begin after age 50
You have neurological symptoms you haven't had before
Prevention strategies aren't working
You're using acute medications frequently

Moving Forward

Chronic migraine can be challenging, but effective prevention strategies exist. By understanding your triggers, working with your healthcare team, and implementing consistent lifestyle changes, you can significantly reduce the impact of migraines on your life.

Remember that migraine is a neurological condition, not just a headache. You deserve comprehensive care and support. With persistence and the right approach, most people with chronic migraine can achieve meaningful improvement.

This guide provides general information about migraine prevention. Work with your healthcare provider to develop a personalized prevention plan.