Migraine prevention should not be defined by arbitrary thresholds, but rather by the use of patient-centered shared decision making. Stephen D. Silberstein, MD, FACP, discusses when to consider initiating preventive therapy, how comorbidities may influence drug choice, and why medication overuse must be addressed before treatment can succeed.

I think that the most important way to look at migraine prevention is by understanding the patient’s experience. If a patient comes in complaining of headache, the major discussion when considering preventive treatment should be about when their headaches come and their impact on the patient, and the answers can vary by patient experience. Many of my patients come into the office due to headache pain almost every day. Their lives are disabled, and it is easier to know what to do for them.

For patients who have infrequent migraines, it is really a joint decision between the patient and the physician. For example, if the patient is a woman who only has migraines with her menstrual cycle, she may need preventive medication, but it is selective and might be something like giving her estrogen before her menstrual cycle. Another example is someone who has 1 debilitating migraine per month, but it interferes with their ability to work. However, in general, the simple rule is that if a patient has 1 or more disabling headache(s) per week, they are considered a candidate for preventive treatment.

It is important to understand what the patient’s goals are. Does the patient want something to take frequently to try to prevent their migraine from coming, or do they want something to take just around the time they start having their headache? It is really the patient’s decision. We can talk about decreasing frequency, becoming pain free, and relieving associated symptoms, but, really, you have to ask the patient and create migraine management goals in the context of their life and what they want.

One of the things that should be built into a discussion on preventive therapies for migraine is the patient’s duration of and response to acute medication. When a new patient comes in, I try to find out what medications they have been on, whether they were on them long enough, and whether there were side effects. Therapy selection can depend on how you give the drug, what the side effects are, and what the patient wants. One reason a patient may fail with a nontargeted medication is they are overusing their acute medications and may develop what is called “medication overuse headache.” When I see a patient who is taking their acute migraine medication very often, or even every day, the first steps are to detoxify them, get them off the overused drug, and then add appropriate preventive treatment. If a patient also has a sleep disturbance, I might consider amitriptyline for preventive therapy. If a patient has concomitant depression, I might consider an SNRI. If a patient has hypertension, I might consider a β-blocker. It can also depend on what else is going on in a patient’s life and whether there is a way to address 2 issues with 1 drug.

One consideration when starting newer targeted migraine therapies is that the patient’s insurance company may only pay for them if the patient has failed several other nontargeted medicines. If the patient is willing to pay out of pocket, then my first choice for chronic migraine prevention is often onabotulinumtoxinA. The reasons I often choose it are because there are not systemic side effects and it is given every 3 months.

So, when I think about migraine prevention, I do not think only about the drug. I think about the patient’s lifestyle, what they prefer, what they have already tried, what else is going on, and whether the current treatment strategy itself is making the headache worse.