Not all patients with episodic migraine require preventive medication. The decision should be based both on disability from headache as well as frequency of headaches. For example, a person with a 2- or 3-day disabling headache once a month, not responding to acute medications, should be on a preventive. On the other hand, a patient with 6 or 8 headaches a month who responds well to acute treatments, does not have increasing frequency or headaches, and has little disability does not need a preventive. About 40% of migraine patients would benefit from preventive therapies, but only about 10% currently receive them. Lifestyle modifications are important. Patients should be counseled to avoid triggers, practice good sleep hygiene, treat stress and depression with medications or behavioral intervention or both. Treating comorbidities such as obesity, hypertension, and chronic neck pain may help. A trial of 2 to 3 months is needed. Preventive treatment need not be life-long. Some patients can taper or stop therapy after 6 months of successful treatment.
Preventive Treatment of Migraine
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