Can chronic migraine be prevented by targeting risk factors?

Migraine is a common chronic disorder with episodic attacks, said Professor Richard Lipton, Albert Einstein College of Medicine, CT.

Treating risk factors might prevent progression to chronic migraine

In the United States, the prevalence of migraine is 18% among women and 6% in men;¹ and every year, episodic migraine progresses to chronic migraine in 2.5% of patients,² he explained.

Many risk factors have been identified for predicting this transition^3–10 and treating them might therefore prevent progression. Although such interventions have not been studied, they are still worth considering and implementing, said Professor Lipton.

Important to address poor response to acute treatment and depression

Inadequate acute treatment efficacy is associated with an increased risk of new-onset chronic migraine, with rates of 1.9%, 2.7%, 4.4% and 6.8% over 1 year among those with maximal, moderate, poor, and very poor treatment efficacy, respectively.¹¹

Improving acute treatment outcomes might therefore prevent new-onset chronic migraine, commented Professor Lipton. This also lowers the risk of medication overuse,⁹ which is another risk factor.

Furthermore, barbiturates and opiates, which are pharmacologic treatment options for acute episodic migraine, are associated with an increased conversion rate to chronic migraine,² so alternative therapies are recommended to avoid this risk.

Depression is a prognostic factor for migraine

Severity of depression also predicts increased risk for new-onset chronic migraine over the following year with OR=1.77 (95% CI 1.25–2.52) for moderate depression, OR=2.35 (95% CI 1.53–3.62) for moderately severe depression, and OR=2.53 (95% CI 1.52–4.21) for severe depression.¹²

Effective treatment of depression might therefore lower the risk for chronic migraine, said Professor Lipton.

Interventions to address other risk factors

Professor Lipton also enumerated the following risk factors for progression and the interventions that might prevent chronic migraine:

• attack frequency³—reduce frequency with pharmacologic and behavioral interventions
• obesity³—manage with weight loss, exercise and bariatric surgery
• comorbidities including depression and anxiety⁴—address with pharmacologic and behavioral therapies
• major life events⁵—implement biobehavioral techniques and exercise for associated stress
• snoring⁶—improve with weight loss and treatment of sleep apnea
• caffeine⁷—lower intake
• allodynia⁸—ensure early recognition and treatment

Efforts to address barriers to care are needed to improve outcomes

Low socioeconomic status⁴ and head injury¹⁰ are further risk factors.

Professor Lipton highlighted that among people with migraine in need of medical care, only 25% traverse the three steps needed—consultation, diagnosis, and treatment/medication use—to achieve minimally appropriate care.¹³ Barriers to care also need to be addressed to improve outcomes, he concluded.