Lifestyle and trigger-based prevention
Non-pharmacological strategies form the foundation of migraine prevention. Consistent sleep scheduling — regular bed and wake times, including weekends — is one of the most impactful measures, as both sleep deprivation and oversleeping can trigger attacks. Regular meals (skipping meals is a common trigger), adequate hydration (at least 1.5–2 litres daily), limiting caffeine to 1–2 cups per day at consistent times, and moderate regular exercise (at least 30 minutes of moderate activity, 3–5 times weekly) have evidence for reducing attack frequency.
Trigger identification through a headache diary is essential but requires nuance — triggers are probabilistic rather than absolute, meaning they lower the threshold for an attack rather than reliably causing one. Common triggers include stress and stress-relaxation phases, hormonal changes (menstrual migraine), weather and barometric pressure changes, bright or flickering lights, strong smells, alcohol (particularly red wine), aged cheeses and processed meats (containing nitrates), artificial sweeteners, and poor sleep. Identifying consistent patterns through 4–8 weeks of diary data allows targeted avoidance strategies without the lifestyle restriction that comes from attempting to avoid all possible triggers simultaneously.
- Consistent sleep schedule — regular bed and wake times
- Regular meals and adequate hydration
- Moderate regular exercise — 30 minutes, 3–5 times weekly
- Caffeine — limit to 1–2 cups daily at consistent times
- Diary-based trigger identification — probabilistic, not absolute
Related: Migraine Care → · Dr. Jitendra Knowledge Hub → · ICHD-3 Topic →
Preventive medication options
Preventive medication is considered when headache frequency is significant (typically 4 or more migraine days per month), when acute medication use is excessive (risk of medication-overuse headache), when migraine substantially impairs quality of life, or when acute treatment is ineffective or contraindicated. The goal is a 50% or greater reduction in attack frequency, though complete elimination is not expected. Medication trials require 2–3 months at adequate dose to assess efficacy — premature discontinuation is a common reason for perceived failure.
First-line oral preventives include beta-blockers (propranolol, metoprolol — effective for migraine without aura), amitriptyline (particularly useful with comorbid tension-type headache, insomnia or depression), and topiramate (useful with comorbid obesity but cognitive side effects may limit tolerability). Newer options include CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) administered monthly or quarterly by injection, and gepants (rimegepant, atogepant) taken orally. These newer agents target the calcitonin gene-related peptide pathway specific to migraine pathophysiology and offer favourable side-effect profiles. Botulinum toxin A is evidence-based for chronic migraine (15 or more headache days per month with migraine features on 8 or more days). Selection is individualised based on attack frequency, comorbidities, patient preference and prior treatment history. Dr. Jitendra Prasad Yadav (NMC 8029) discusses preventive options at Kathmandu Neurology Clinic & Cognitive Center, Durbar Marg, Opposite of Yak & Yeti Hotel.
- Beta-blockers (propranolol) — first-line, especially without aura
- Amitriptyline — useful with comorbid tension-type headache or insomnia
- Topiramate — effective, cognitive side effects possible
- CGRP monoclonal antibodies — monthly or quarterly injection
- Botulinum toxin — evidence-based for chronic migraine