When should I consider a preventive treatment for migraine? 

First and foremost, YOU are the one who should make this decision, based on your personal situation. There is no official absolute rule. Your physician or nurse practitioner can discuss options with you. 

  • Clues that a preventive approach could be considered
    You have more than 1 day of migraine per week
    Your attacks are severe, difficult to control and disabling You have attacks that still impact your function despite taking an acute medication
  • Situations where a preventive treatment is strongly recommended
    You have more than 2 days of attack symptoms per week (or more than 8 per month).
    Your quality of life or function is impacted by migraine.
    You are using acute medication close to 8 days of the month. 

If any of these apply, you are at risk for migraine chronification and medication-overuse, and you should definitely consider prevention.

If I start a preventive, will I have to take it all my life?

Preventive agents are not necessarily used for many years. After 8-12 months of successful treatment, one could slowly taper and try to discontinue the preventative medication. If migraine attacks increase, then the treatment is still needed and may be continued. 

Long term treatment may be required for some people. Research shows that continuing with a preventive increases the chances of remaining stable on the long term. If something works, keep doing it! 

Isn’t it excessive to use medications on the long term for migraine?

Sometimes preventives are needed to maintain a good quality of life.

Migraine is a neurological disease that may justify the use of long-term medication, just like any other chronic disease. Diabetes, thyroid diseases, and hypertension all require long time treatments. Understanding that migraine is a disease and is not a result of your behaviour or self-care is a more positive perspective. Achieving zero migraine attacks and freedom from medication is not always possible. The ultimate goal is to reduce migraine frequency and achieve a good quality of life with minimal impact on your function.

Long term risks of migraine preventives are discussed on another page (See this post)

What are situations that could allow me to stop migraine preventives?

Here are five situations where migraine can be drastically improved and preventive medications might be stopped: 

  • Retirement 
  • Menopause (especially in women with hormone-sensitive migraines)
  • Resolution of a major personal stressor or conflict 
  • Successful management of a major medical issue (sleep apnea is a common example)
  • Radical and sustained changes in your lifestyle 

What is «the virtuous circle of migraine»?

Using migraine preventives can lead to a virtuous circle that may allow you to stop the drug
It’s easier to adopt a healthy, migraine-friendly lifestyle when one is feeling better and life becomes more predictable. Anxiety and depression may disappear as you gain back control over your life. Migraine frequency may drop even further, and the preventive might be stopped.  

Are there situations where the preventive will stop working?

That may happen. But before concluding that your preventive does not work, consider the following possibilities.

  • Migraine tends to fluctuate spontaneously. Maybe this is a just a bad phase. 
  • Is the deterioration caused by a factor that can be addressed, like a major change in stress levels or lifestyle? 
  • Is it possible that you have reset your normal? It is common that as people get better, they may feel that 6 days of migraine symptoms is bad. However, when they were having 12 days per month, 6 was actually quite good. 

I think I want to stop the preventive. How do I do that?

Always use a diary before changing anything. Discuss with your health care provider. An option may be to decrease the dose a little. If you decide to taper down, do it very slowly. Never stop a migraine preventive abruptly. It may lead to severe rebound migraine attacks.

REFERENCES

VanderPluym J, Evans RW, Starling AJ. Long-Term Use and Safety of Migraine Preventive Medications. Headache. 2016;56(8):1335-43.

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