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 health care provider 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
  • Situations where a preventive treatment is strongly recommended
    You have more than 2 days of attack per week.
    Your quality of life is clearly impacted by migraine
    In this situation, you are at risk for 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 migraines come back, then the drug is still justified and may be continued. 

Still, long term treatment may be required. Research shows that keeping 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 keep a good quality of life on the long term 

Migraine is a neurological disorder that may justify the use of long-term medication, just like any other chronic disease. Diabetes, thyroid diseases, hypertension all may require long time treatments. Readjusting your expectations can be very positive over time. No migraines and no drug is not always possible. The ultimate goal is to reach a good quality of life and decrease migraine frequency.

Long term risks of migraine preventives are discussed in 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 not rare to see people who get better readjusting and finding that 6 days per month is bad, but when they were having 12 days, 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 increase the dose a little. If you decide to taper down, do it progressively. Never stop a migraine preventive abruptly. It may lead to severe rebound migraines. Use

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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