Migraine prophylaxis: Over-the-counter treatment options

Prophylactic treatments for headache pain are especially relevant for patients suffering from migraine headaches. However, migraine symptoms can overlap with many symptoms of other headache types resulting in an incorrect diagnosis (the correct diagnosis, of migraine, is often overlooked) and inadequate management of their headache pain.

In addition, some patients have mixed headache syndrome (or transformed migraine; coexisting migraine and tension-type headaches), in which a medicine for one type of headache may be effective for another headache type in the syndrome. In these cases, the diagnosis and resulting acute treatment plan may be less than ideal. This occurs frequently with post-traumatic headaches.

Sometimes, even with effective rescue treatments, a person can still miss significant life events, work, or family time. When your patient is unhappy with pain and symptom control, and they have managed their triggers with little effect, prophylactic treatment should be considered.

Reviewing a patient’s headache diary will yield information about both headache frequency and duration. If patients record the effect of headaches on interactions with their loved ones or on their function at work, you can get a good idea of how they are affected.

Here’s a list of things you should consider when trying to determine if your patient is ready for prophylactic treatment:

• What is a reasonable number of headaches a patient should be allowed to suffer before we consider prophylactic therapy?
• How does the number of headache days endured by a patient affect their function?
• Does the patient’s rescue regimen work for them? If so, all the time? Or is there room for improvement?
• How does the patient feel about a daily medicine to decrease the frequency and / or severity of headache events?

Once you’ve decided that your patient is ready for a prophylactic approach to headache pain management, there are over-the-counter medicines and prescription drugs to choose from.

We recommend certain over-the-counter supplements as prophylaxis for all patients, whether they take prescription medication or not. Over-the-counter regimens can be especially helpful when a patient is unwilling to try a prescribed drug. If they have a measurable response, it may sway a patient to try something more efficacious.

These over-the-counter preparations are magnesium oxide (400–800 mg daily) and riboflavin, or vitamin B2 (400 mg daily). Other treatments which may have a beneficial effect include coenzyme Q10, vitamin B12, feverfew, and butterbur.

There are three major goals of preventative therapy:

1. Reducing headache frequency by at least 50%
2. Reducing headache severity and duration
3. Increasing the efficacy of abortive or symptomatic therapies

If you begin by explaining the goals of the therapy, your patient will be able to use a headache diary to focus on the efficacy of treatment and quantify their response.