Migraine Management: Prevention and Treatment Guide

Log: date and time of onset, duration, pain intensity (1-10), location (one side or both), associated symptoms (nausea, light sensitivity, aura), what you ate and drank in the 24 hours before, sleep quality the previous night, stress level, weather changes, menstrual cycle day (if applicable), and what treatment you used and how well it worked. Use an app (Migraine Buddy, free) or a simple notebook. After 4-6 weeks, patterns emerge. Share this diary with your doctor because it is more reliable than memory for identifying patterns.

Common migraine triggers: sleep changes (too little or too much), skipped meals, dehydration, stress (or the let-down after stress), hormonal changes (menstruation, ovulation), weather changes (barometric pressure drops), alcohol (especially red wine), aged cheeses, processed meats (nitrates), MSG, strong smells, bright or flickering lights, and screen overuse. Most people have 2-5 primary triggers. A single trigger alone may not cause a migraine, but stacking triggers (poor sleep plus skipped meal plus stress) often crosses the threshold. Eliminating your top triggers can reduce attack frequency by 30-50%.

If you experience 4 or more migraine days per month, 8 or more headache days per month, or if migraines significantly impair your functioning despite acute treatment, you are a candidate for preventive therapy. Chronic migraine is defined as 15 or more headache days per month (at least 8 with migraine features) for 3+ months. Accurate tracking is essential because most people underestimate their migraine frequency. Your neurologist uses these numbers to select the right preventive approach and to measure whether treatment is working.

Triptans (sumatriptan, rizatriptan, eletriptan) are the most effective acute migraine medications. They work best when taken early: 60-70% pain-free rate within 2 hours when taken at mild pain versus 30-40% when taken at severe pain. Sumatriptan 100 mg (generic: 2-10 USD per tablet) is the most common starting triptan. If you get aura, take the triptan when the headache phase begins (not during aura). NSAIDs (ibuprofen 400-600 mg, naproxen 500 mg) are effective for mild to moderate migraines and can be combined with a triptan for severe attacks.

Medication overuse headache (MOH) occurs when acute medications are used too frequently: triptans more than 10 days per month, NSAIDs more than 15 days per month, or combination analgesics more than 10 days per month. MOH transforms episodic migraine into daily or near-daily headache that paradoxically requires the overused medication to temporarily relieve. If you need acute medication more than 2-3 times per week, this signals the need for preventive therapy rather than more acute treatment. Breaking the MOH cycle requires stopping the overused medication, which temporarily worsens headaches for 1-2 weeks.

If your triptan does not work within 2 hours, options include: a different triptan (response varies between triptans; if one fails, another may work), anti-nausea medication (ondansetron 4-8 mg, which also has migraine-relieving properties), or a steroid burst (dexamethasone, prescription required). For migraines lasting over 72 hours (status migrainosus), urgent care or an ER visit for IV fluids, IV anti-nausea medication, and IV ketorolac (a powerful NSAID) can break the cycle. Discuss a written rescue plan with your neurologist before you need it.

Traditional preventive medications: topiramate (50-100 mg daily, 10-20 USD per month, also causes weight loss), propranolol (80-160 mg daily, 10-15 USD per month), amitriptyline (10-50 mg at bedtime, 5-10 USD per month, also helps sleep). These reduce migraine frequency by 50% in about 40-50% of patients. Newer CGRP inhibitors (Aimovig, Ajovy, Emgality: monthly injections, 500-700 USD per month before insurance) are more targeted with fewer side effects and reduce frequency by 50% in 50-60% of patients. Most insurance covers CGRP inhibitors after failing 2 traditional preventives.

OnabotulinumtoxinA (Botox) is FDA-approved for chronic migraine and involves 31 injections in specific head and neck locations every 12 weeks. It reduces headache days by 8-9 per month on average. Cost: 1,500-2,500 USD per session, covered by most insurance for chronic migraine after failing 2-3 other preventives. Effects take 2-3 treatment cycles (6-9 months) to reach full benefit. Side effects are mild: temporary neck pain and injection site soreness. Botox is administered by neurologists or headache specialists trained in the specific injection protocol.

Three supplements have strong clinical evidence for migraine prevention: magnesium glycinate or citrate (400-600 mg daily, reduces frequency by 40% in one trial), riboflavin/Vitamin B2 (400 mg daily, reduces frequency by 50% in clinical trials), and CoQ10 (100 mg three times daily, reduces frequency by 50% in some studies). These supplements are inexpensive (10-20 USD per month each), have minimal side effects, and can be combined with prescription preventives. Allow 2-3 months to assess effectiveness. Butterbur (Petadolex) also has evidence but has liver toxicity concerns.

Both too little and too much sleep trigger migraines. Weekend sleep-ins of 2+ hours beyond your weekday wake time are a common trigger (weekend migraine syndrome). Aim for 7-8 hours per night with less than 30 minutes variation in bedtime and wake time. Sleep hygiene: dark room (use blackout curtains), cool temperature (65-68 degrees F), no screens 30-60 minutes before bed, and consistent bedtime routine. Insomnia treatment with CBT-I reduces migraine frequency by 30-40% in patients with co-occurring sleep problems.

Fasting and meal-skipping trigger migraines by causing blood sugar drops. Eat within 1 hour of waking and do not go more than 4-5 hours without food during the day. Dehydration is a top-five migraine trigger. Drink at least 8 glasses (64 ounces) of water daily, more in hot weather or with exercise. Many migraine patients report that their first symptom is thirst. Carry a water bottle and set reminders to drink if you tend to forget. Adding electrolytes (Liquid IV, LMNT) may be more effective than water alone for dehydration-triggered migraines.

Stress is the most commonly reported migraine trigger (reported by 70-80% of patients). Paradoxically, the let-down after a stressful period is an even stronger trigger (weekend and vacation migraines). A daily relaxation practice reduces overall stress reactivity. Options: progressive muscle relaxation (15 minutes daily, reduces migraine frequency by 30-50% in studies), mindfulness meditation (10-20 minutes daily), deep breathing exercises, or yoga. The key is daily practice, not just using these techniques during a migraine. Consistent practice changes your baseline stress response. This guide is informational only, not medical advice.