Evidence-Based Clinical Protocol for Migraine Treatment

Medication Treatment

Acute attack therapy. The goal of treating an acute migraine attack is to relieve pain and accompanying symptoms as quickly as possible and restore the ability to function. The choice of medication depends on the intensity of the attack and the individual characteristics of the patient. For mild to moderate attacks, non-opioid analgesics are recommended, especially nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, acetylsalicylic acid (aspirin), naproxen and diclofenac, or combination analgesics with caffeine. For moderate to severe attacks, and when simple analgesics are not effective enough, migraine-specific medicines are prescribed, primarily triptans. Triptans (sumatriptan, zolmitriptan, rizatriptan, eletriptan and others) are agonists of the serotonin 5-HT_1B/1D receptors and are highly effective for stopping migraine: about 70–80% of patients get relief within 2 hours. They are recommended to be taken as early as possible after the pain begins. If triptan monotherapy has an insufficient effect, it is reasonable to increase the dose to the maximum or to try a different triptan for the next attack. It has been shown that a combination of sumatriptan (50–100 mg orally) with naproxen (550 mg) gives a better result in patients with a partial response to a triptan than either drug alone. Dihydroergotamine (DHE), an ergotamine derivative, can be used as an alternative vasoconstrictor (intranasally or by injection) for severe attacks, although it is tolerated less well than triptans. To relieve nausea and vomiting during migraine, antiemetics are additionally prescribed: metoclopramide or prochlorperazine (especially intravenously in a hospital setting). In the emergency department, these medicines (intravenous metoclopramide, prochlorperazine) are recommended as first-line options, and intravenous dexamethasone may be added to help prevent recurrence of the headache. Opioids should be avoided in migraine because they are not specifically effective and increase the risk of misuse (morphine, hydromorphone and other opioids are recommended not to be used). For patients with pronounced nausea or vomiting, it is useful to use non-oral forms of medication: suppositories, nasal sprays (for example, intranasal sumatriptan or zolmitriptan) or subcutaneous sumatriptan injections, which ensure absorption even when oral intake is impaired.

Choosing acute attack therapy according to severity: for mild to moderate attacks, NSAIDs, non-opioid analgesics (paracetamol) or combination products with caffeine are effective; for moderate or severe attacks (and for milder ones that do not respond to treatment), migraine-specific medicines such as triptans or dihydroergotamine should be used right away; newer options (gepants, ditans) are reserved for cases of treatment failure or contraindications to triptans.

The strategy can be "stratified" (the level of therapy is chosen immediately according to the severity of the attack) or "stepwise" (step care: starting with a simpler medicine and moving to a stronger one if it fails). Current guidelines favor the stratified approach because it leads to faster relief and higher patient satisfaction than gradual stepwise escalation. However, where resources are limited or in mild cases, a stepwise approach may also be used: for example, the European Headache Federation (EHF) recommends trying NSAIDs for the first three migraine attacks and moving on to triptans only if they are ineffective; if three different triptans have no effect, a switch to another class of medicines (gepants or ditans) should be considered. Gepants are oral CGRP receptor antagonists (ubrogepant, rimegepant and others) that have appeared recently; ditans are 5-HT_1F receptor agonists (lasmiditan), also a new class. They can be used to stop an attack in patients for whom triptans are contraindicated (because of cardiovascular disease) or ineffective. According to the consensus, gepants and ditans should be prescribed only after at least two different triptans have been tried, because there are no direct data showing their superiority over triptans, and they are also expensive. In some cases, when an attack lasts more than 72 hours (status migrainosus) or does not respond to standard therapy, hospitalization and intravenous infusions are used: DHE, metoclopramide, or valproate, magnesium sulfate and glucocorticoids. It is also important to warn the patient about medication overuse: taking symptomatic medicines too often can itself lead to chronic pain (medication-overuse headache). The general recommendation is to limit the use of acute (rescue) medication to no more than 2 days a week (no more than 8 days a month for triptans or combination analgesics; no more than 10–15 days for NSAIDs). If a patient needs to treat attacks more often, preventive treatment should be considered.

Preventive (interictal) therapy. Preventive treatment of migraine aims to reduce the frequency and intensity of attacks and improve quality of life. The decision to start it is made for frequent or severe migraines: the general recommendation is to offer prevention if migraine occurs on 4 or more days a month, or less often if the attacks are very severe or cause significant disability. Other indications are ineffectiveness, contraindications or poor tolerability of acute medications. Preventive medicines are taken daily (regardless of whether there is pain) as a long course. Effectiveness can be assessed after 2–3 months, and the optimal course is at least 6 months. Treatment starts with low doses and the dose is increased slowly until effective, in order to minimize side effects.

The main groups of medicines for migraine prevention with a high level of evidence (level A according to clinical guidelines) include beta-blockers, certain anticonvulsants, and anti-CGRP antibodies. First-line beta-blockers: propranolol (80–240 mg/day), metoprolol (50–200 mg), timolol or atenolol, which reduce the frequency of attacks through their effect on the adrenergic system. They are among the longest-used preventive medicines, and their effectiveness has been confirmed in controlled studies (a reduction in migraine frequency of about 50% in a significant proportion of patients). Anticonvulsants: topiramate (50–100 mg/day) and valproic acid/sodium valproate (500–1500 mg/day) also have proven effectiveness (level A). Topiramate is recommended as one of the drugs of choice for preventing episodic migraine, but the dose should be adjusted slowly because of possible side effects (paresthesia, cognitive complaints and others). Valproate is effective, but its use is limited because of teratogenicity and it is undesirable in women of reproductive age (it should not be prescribed to women who could become pregnant without reliable contraception). Antidepressants: amitriptyline (a tricyclic antidepressant) is used most often, at doses of 10–75 mg at night; it can reduce migraine frequency, especially in patients with coexisting chronic tension-type headache or sleep disorders. Amitriptyline has evidence level B (good effectiveness, although there are fewer data). Venlafaxine (75–150 mg/day, an SNRI antidepressant) is an alternative, also level B. Current guidelines advise against prescribing flunarizine (a calcium channel blocker available in some countries) or cinnarizine without strict supervision because, although they may be effective, their side effects (sedation, weight gain, extrapyramidal symptoms) limit their use. Angiotensin II receptor blockers: candesartan (16–32 mg/day) has proven effectiveness comparable to propranolol and is considered a first-line option (level A), especially when beta-blockers are contraindicated. Calcium channel blockers (for example, verapamil) are also used in some patients, but the evidence base for them in migraine is weaker, except in special situations (verapamil is used more often in cluster headache).

Monoclonal antibodies against CGRP (or its receptor) are the newest class of preventive medicines, developed specifically for migraine. They include erenumab (an antibody to the CGRP receptor) and galcanezumab, fremanezumab and eptinezumab (antibodies to the CGRP ligand). These medicines are given subcutaneously or intravenously once every 1–3 months and have shown high effectiveness in reducing the number of migraine days in both episodic and chronic forms, with minimal side effects. For example, in studies the antibodies reduced the frequency of migraine days by about 50% in half of the patients who had not responded to earlier oral preventive medicines. Given the cost, most international protocols recommend using CGRP antagonists in patients who have not succeeded with at least two conventional preventive medicines. However, some experts believe that, in the absence of contraindications, they can also be considered as a first-line option in patients with frequent and severe migraines, given their high effectiveness and better tolerability compared with older medicines. Anti-CGRP antibodies should not be prescribed to pregnant or breastfeeding women, or to patients with uncontrolled cardiovascular disease or severe mental disorders (because of the lack of experience in these groups). Botulinum toxin type A (onabotulinumtoxinA), injected according to a set pattern into the muscles of the head and neck, is an evidence-based method of preventing chronic migraine (migraine on 15 or more days a month). The medicine is given at 155–195 units every 12 weeks and has been shown to reduce headache frequency in the chronic form. It is officially approved for chronic migraine and is included in protocols as a treatment option of choice for such patients. According to studies, botulinum toxin is not effective for episodic migraine.

In general, the choice of preventive medicine is individualized according to coexisting conditions: for example, beta-blockers are preferred in hypertension or tachycardia; venlafaxine or amitriptyline in coexisting depression; topiramate in obesity or epilepsy; and botulinum toxin or CGRP antibodies in chronic migraine. Sometimes success is achieved by combining two preventive medicines at lower doses, although data on combination therapy are still limited. It is important to adjust the dose gradually and to keep a headache diary. If migraine is well controlled, after 6–12 months it may be possible to try gradually withdrawing the preventive medicine. The patient should be warned that the effect of prevention does not appear immediately, and should be reminded of the importance of avoiding excessive use of acute medications, which can undo the success of prevention.

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Physiotherapy (Neurostimulation) Methods

In addition to drug therapy, non-drug device-based methods of treating migraine are becoming increasingly important. They include various forms of neurostimulation, both non-invasive (through the skin) and invasive, which modulate the nervous system and may reduce the frequency or intensity of attacks. Many of these methods are relatively new, but they already have an evidence base for effectiveness in migraine.

• Transcranial magnetic stimulation (TMS). The method generates magnetic pulses that pass through the skull and induce electrical currents in the brain. In migraine, both single-pulse TMS for stopping attacks with aura and repetitive TMS (rTMS) at low or high frequency for prevention have been studied. Data on acute treatment: one placebo-controlled trial showed that single-pulse TMS applied to the back of the head during aura increased the percentage of people whose headache did not develop or had resolved within 2 hours, compared with sham stimulation. This was the basis for approval of the portable sTMS device (SpringTMS, USA) for self-treatment of migraine attacks. For migraine prevention, rTMS has been studied more. A 2020 meta-analysis found that high-frequency rTMS of the motor cortex (M1) has a statistically significant, although moderate, effect in reducing migraine frequency. Other protocols (for example, rTMS of the prefrontal cortex) have not yet shown convincing benefit. TMS is well tolerated; typical sensations are light tapping on the scalp and sometimes dizziness. Contraindications: metal implants or stimulators in the body, and epilepsy (because of the risk of provoking seizures with rTMS). Overall, transcranial magnetic stimulation is regarded as an additional method, especially for patients with aura and an insufficient response to medication.
• Transcutaneous electrical nerve stimulation (TENS). This is non-invasive electrical stimulation through the skin, usually of the nerves of the forehead or the back of the head. The best-known device is Cefaly, a headband electrostimulator of the supraorbital branch of the trigeminal nerve. A 2013 randomized controlled trial (PREMICE) showed that using Cefaly for 20 minutes daily led to a significant reduction in the monthly number of migraines compared with a placebo device. A more recent meta-analysis confirmed that supraorbital TENS has a small but statistically significant preventive effect. As a result, this method is approved in the USA and Europe for the prevention of episodic migraine. It is non-invasive and practically safe (the side effect is skin irritation). For patients who want non-drug prevention, a trial course of TENS can be recommended. Other electrostimulation methods: occipital nerve stimulation (ONS), in which electrodes are implanted next to the occipital nerves, showed a pronounced effect in refractory chronic migraine (a reduction in attack frequency, with a large effect), but it is an invasive procedure and results vary. Because of its invasiveness, ONS is reserved for the most severe cases that have not responded to anything else.
• Vagus nerve stimulation. Non-invasive vagus nerve stimulation (nVNS) with a portable device (for example, gammaCore) has been studied in migraine. The mechanism is electrical stimulation of the cervical portion of the vagus nerve through the skin. Some studies point to a reduction in pain intensity when nVNS is used during an attack, and to a possible preventive reduction in frequency with regular use twice a day. However, in a 2020 meta-analysis the effect of nVNS on prevention on its own did not reach significance (probably because of the small amount of data). At the same time, nVNS is FDA-approved for the treatment of cluster headache and is an attractive option for patients who do not tolerate medications. As migraine prevention, this method may be useful as an addition, especially in the presence of vagotonia or anxiety disorders, but further research is needed.
• Transcranial direct current stimulation (tDCS). This method applies a weak direct electric current through skin electrodes to modulate the excitability of areas of the cortex. Studies of tDCS in migraine so far give conflicting results. Some small randomized controlled trials showed that anodal tDCS of the occipital (visual) cortex may raise the excitability threshold of the brain and reduce migraine frequency, while others found no difference compared with sham stimulation. A 2019 meta-analysis noted that the evidence is insufficient for clear conclusions. For now, tDCS should be regarded as an experimental method; research continues to optimize its parameters (the site of application, frontal or occipital cortex, current polarity, session duration and so on). The method is non-invasive and safe, so where the equipment is available it can be used as an adjunct (some patients report improvement).
• Laser therapy (low-level laser radiation). This approach uses a low-power laser to biostimulate tissues. In migraine, so-called laser acupuncture has been studied: laser irradiation of acupuncture points associated with the head. A recent randomized trial from 2024, involving 60 patients with chronic migraine, showed that adding 810 nm laser acupuncture (8 sessions over 4 weeks) to standard therapy significantly reduced the number of migraine days and the need for analgesics compared with a placebo laser. Within 8–12 weeks, migraine days in the laser therapy group fell by 5–7 days a month on average, while in the placebo group they fell by only about 1–2 days. Importantly, no side effects were found. These are encouraging data suggesting that low-level laser therapy may be an effective addition to the prevention of chronic migraine. The mechanism of the laser's action is explained by improved microcirculation, an anti-inflammatory effect and stimulation of mitochondrial metabolism in neurons. Although the method is not yet part of standardized guidelines, it can be considered in refractory cases or when drug prevention is not possible.

Conclusion on physiotherapy: Non-invasive neurostimulation methods are promising and useful additions in the treatment of migraine. According to a systematic review, the most promising are: for acute pain, remote electrical neuromodulation (REN, a device worn on the forearm that activates nociceptive fibers and reduces pain reflexively); for prevention, permanent ONS (invasive, for chronic migraine), transcutaneous stimulation of the trigeminal nerve (Cefaly), percutaneous electrical nerve stimulation (PENS) and rTMS of the motor cortex. All of these showed a statistically significant reduction in migraine frequency (although a moderate one). Other methods, such as vagus nerve stimulation or tDCS, have not yet confirmed their effectiveness (more data are needed). It is important to note that the quality of evidence for most physiotherapy approaches is currently moderate, so they should be used as additions to the main treatment, especially in patients who want to reduce their medication load.

Nutraceuticals (Supplements and Trace Elements)

Various dietary supplements and vitamins can play a supporting role in migraine prevention. They are attractive because they are usually safe, inexpensive and well tolerated, so they are often chosen by patients who prefer "natural" methods or who have contraindications to medications. It is important that the doctor knows about these products and coordinates their use as part of the overall plan.

The best-known nutraceuticals for migraine are magnesium, riboflavin (vitamin B₂), coenzyme Q10 and melatonin, as well as the herbal extracts feverfew and, formerly, butterbur. Current guidelines even classify magnesium, riboflavin and CoQ10 as having evidence level B (may be recommended) for migraine prevention. Each of these nutraceuticals is described briefly below:

• Magnesium. Magnesium deficiency is associated with the pathogenesis of migraine: in some studies, reduced magnesium levels were found in the serum and brain of patients during attacks. Magnesium is a cofactor in many neuronal processes; in particular, it inhibits NMDA receptors and reduces the release of excitatory neurotransmitters. Randomized trials showed that taking magnesium (most often magnesium citrate or oxide) at a dose of about 600 mg a day reduces the frequency of migraine attacks compared with placebo. Magnesium may be especially effective in migraine with aura and in menstrual migraine. Given its safety profile, the American Headache Society recommends magnesium as a component of prevention for many patients. Side effects are mainly diarrhea (magnesium has a laxative effect), so forms with better intestinal tolerance (magnesium glycinate) are sometimes chosen. Magnesium can also be given intravenously during acute migraine attacks with aura, which reduced pain intensity in some studies.
• Riboflavin (vitamin B₂). It is used at a high dose of 400 mg/day. Its mechanism of action probably lies in improving the energy metabolism of mitochondria in neurons, since mitochondrial dysfunction is thought to play a role in migraine. Clinically, several placebo-controlled studies (Boler et al., 1998; Schoenen et al., 1998) showed a significant reduction in migraine frequency with riboflavin taken for 3 months. Although these studies were relatively small, meta-analyses support the benefit of riboflavin. Therefore, riboflavin 400 mg daily is recommended by many guidelines as a safe means of prevention. Side effects are minimal (bright yellow urine and, rarely, diarrhea at very high doses).
• Coenzyme Q10. This substance is also involved in mitochondrial energy metabolism. Studies showed that taking CoQ10 at a dose of 100 mg three times a day (300 mg/day) may reduce migraine frequency after as little as 3 months. In one placebo-controlled study in 2005 (Sandor et al.), 61% of patients on CoQ10 achieved a reduction in migraine frequency of 50% or more, compared with 14% in the placebo group (p<0.05). Even combined supplements containing CoQ10, magnesium and riboflavin have been tested: in the multicenter Migravent® study, reduced pain intensity and improved quality of life (HIT-6) were shown with this combination. Although the primary endpoint (reduction in the number of migraine days) formally did not reach statistical significance, the overall trend favored active treatment. For this reason CoQ10 (300 mg/day) is considered a useful addition. The product is safe; it can occasionally cause insomnia, so it is recommended to take it no later than lunchtime.
• Melatonin. This is a hormone of the pineal gland that regulates circadian sleep rhythms. Melatonin is of interest because sleep and circadian rhythm disturbances are often associated with migraine. Several studies have shown the effectiveness of melatonin 3 mg at night in reducing migraine frequency. In one randomized controlled trial (2016, Cephalalgia), melatonin 3 mg was not inferior to amitriptyline 25 mg in migraine prevention, with better tolerability (less next-day sleepiness), and it also outperformed placebo in the percentage of patients with an improvement of 50% or more. Melatonin may therefore be useful, especially in patients with sleep disorders or those who do not tolerate amitriptyline. Its advantage is that it also improves sleep. The recommended dose is 3–5 mg 30 minutes before bedtime.
• Feverfew. A herbal extract, a traditional remedy for headache. Its mechanism is attributed to its parthenolide content, which may inhibit the release of serotonin from platelets and reduce neuroinflammation. Data on effectiveness are conflicting: early studies in the 1980s–90s gave mixed results. However, the standardized extract MIG-99 showed a significant reduction in migraine frequency compared with placebo in two German randomized controlled trials. According to a Cochrane review (2015), the data overall are insufficient for firm conclusions, but some patients do feel a benefit. Feverfew was included in older guidelines as an option (level C). Today the AHS mentions it as a popular nutraceutical, although the scientific support is limited. Side effects: mouth ulcers and stomach upset; with long-term use, abrupt withdrawal can cause a withdrawal syndrome with headache.
• Butterbur (petasites) extract. In the past a very promising herbal remedy: two randomized controlled trials (Lipton et al. 2004; Diener et al. 2004) showed that butterbur root extract at a dose of 75 mg twice a day significantly reduces migraine frequency (about a 48% reduction vs about 26% with placebo). On the basis of these data, the American Academy of Neurology included butterbur in its recommendations in 2012 (level A). However, it later emerged that some butterbur products contain hepatotoxic alkaloids (pyrrolizidine alkaloids, PAs), which can cause severe liver damage. As a result, quality brands are obliged to remove PAs (labeled "PA-free"). Because of safety concerns, butterbur is now not recommended by most experts, despite its effectiveness. If a patient still wishes to take it, liver function should be monitored and only a guaranteed PA-free extract should be used.
• Other supplements. Vitamin D deficiency is linked to frequent headaches; several small studies showed that correcting a vitamin D deficiency (2000–4000 IU per day) may reduce the frequency of attacks, especially in patients with initially low levels. Vitamin B12 (cyanocobalamin) is sometimes added because a shortage of it can contribute to neurological symptoms, but a specific effect in migraine has not been proven. Omega-3 polyunsaturated fatty acids: a diet rich in omega-3 (fish oil) and low in omega-6 showed, in a 2021 randomized controlled trial, a reduction in the duration and intensity of headache in migraine; omega-3 fatty acids have an anti-inflammatory effect. Therefore fish oil 2–3 grams a day can be recommended as an addition. Alpha-lipoic acid is an antioxidant; small studies (2005, 2007) gave inconsistent results: one showed a 37% reduction in migraine frequency with 600 mg of ALA, while another did not confirm this. More data are needed. In general, nutraceuticals should be chosen individually: they can be combined with each other and with medications. Combinations are often used: magnesium + B₂ + Q10, because they act on different links in the process and are well tolerated. If the patient prefers non-drug prevention, these supplements can be a first step, but it is worth keeping a diary and checking the effect after 2–3 months.

Psychotherapeutic and Psychosocial Approaches

In the management of migraine, great attention is paid to psychosomatic aspects, stress triggers and methods of psychological support. Stress is a known trigger of migraine, and chronic pain, in turn, leads to anxiety and depression in a significant proportion of patients. Therefore cognitive behavioral therapy (CBT) and other behavioral interventions, which aim to change the perception of pain and teach stress management and relaxation skills, are an important part of a comprehensive approach.

• Cognitive behavioral therapy (CBT). This is structured therapy with a psychologist that teaches the patient to recognize and modify negative thoughts and behavioral reactions related to pain. CBT methods help reduce anticipatory anxiety about attacks, cope with fear of pain and develop coping strategies. A 2021 systematic review and meta-analysis confirmed that CBT in migraine significantly reduces headache frequency and disability scores on the MIDAS compared with usual treatment. In the included randomized studies, CBT over 8–12 sessions achieved a reduction in migraine attack frequency of about 30–50%, which is comparable to drug prevention. Improvements in quality of life and reductions in anxiety and depressive symptoms were also noted. Side effects are minimal; temporary worsening of headache or the emergence of intense emotions during therapy has rarely been reported. CBT therefore has evidence level A in migraine prevention (according to the US Headache Consortium) and can be recommended as an effective option, especially for patients with frequent migraines and coexisting emotional disorders.
• Relaxation techniques. Training in muscle and mental relaxation lowers the overall level of stress and autonomic arousal. The most common technique is Jacobson's progressive muscle relaxation (PMR), which involves tensing and relaxing different muscle groups in sequence with a focus on the sensations. Breathing exercises and autogenic training are also used. Relaxation is a simple and inexpensive method that the patient can practice independently every day. Unexpectedly, it has a solid evidence base: PMR is considered to have evidence level A for migraine prevention (that is, its effectiveness has been confirmed by at least two independent randomized controlled trials). In particular, in the Swedish study by Varkey (2011), relaxation therapy three times a week was not inferior to either physical exercise or topiramate in reducing migraine frequency. An additional benefit is better sleep and less muscle tension in the neck. Patients are therefore advised to learn relaxation methods (ideally at first under the guidance of a psychologist or physiotherapist) and to use them regularly, and also during the prodromal phase of migraine to potentially prevent an attack from developing.
• Biofeedback. In this method, devices show the patient his or her physiological parameters (muscle tension, skin temperature, pulse and so on) and the patient is taught to control them consciously. In migraine, the most commonly used forms are thermal biofeedback (raising the temperature of the hand through vasodilation) and EMG biofeedback (reducing tension in the forehead and neck muscles). The aim is to teach the patient to induce peripheral vascular dilation and muscle relaxation, which is associated with a calm state. A 2019 meta-analysis (Nestoriuc et al.) showed that biofeedback reduces migraine frequency by about 45% versus about 14% in controls, that is, it is significantly effective. Guidelines (AAN, AHS) classify biofeedback among methods with level A evidence. Its drawbacks are that it needs special equipment and a trainer; however, home devices and apps are now appearing. Biofeedback can be combined with relaxation and CBT for a better result.
• Mindfulness and meditation methods. Mindfulness-based stress reduction (MBSR) is a program that includes training in mindful meditation, body scanning and yoga. In chronic pain, MBSR has established itself as a way to reduce reactivity to pain. For migraine, an adapted version, Mindfulness-Based Cognitive Therapy for Migraine (MBCT-M), which combines mindfulness with elements of CBT, showed in studies a reduction in disability (HDI, MIDAS) and improved quality of life. In one randomized controlled trial in 2019, MBCT-M significantly reduced migraine disability compared with a waiting list, in particular lowering the disability score (MIDI). Participants also reported lower pain intensity. Meditation practice (about 20–30 minutes a day is needed) helps change the perception of pain: the patient learns to accept sensations without panic, which often reduces subjective suffering. Mindfulness and meditation techniques can therefore be recommended as part of a treatment program; they are safe and have additional positive effects (less anxiety and depression, better sleep).
• Psychotherapeutic education and support. It is important for the patient to understand the nature of the condition, the role of triggers and the significance of preventive measures. Educational sessions with a doctor or nurse (so-called headache school) improve adherence to treatment and self-control. Patients are told about the importance of following a regular routine, keeping a headache diary and taking medication promptly at the start of an attack. Support groups or online programs for people with migraine are also effective: sharing experience and learning cognitive and behavioral skills. Studies show that taking part in such programs reduces the depression and anxiety associated with migraine and may even lower attack frequency through better adherence to a healthy lifestyle.

In summary, psychotherapeutic interventions (CBT, relaxation, biofeedback, mindfulness) are effective non-drug means of migraine prevention, with effectiveness comparable to that of drug therapy (a reduction in attack frequency of about 30–50%). They are worth offering to all patients with chronic migraine or a marked impact of the condition on their life, especially if there are coexisting emotional disorders or contraindications to medication. Combining several methods (for example, CBT + relaxation + drug prevention) is generally reported to give the best results.

Other Supportive Measures (Routine and Lifestyle)

In addition to specific treatment interventions, success in controlling migraine depends to a large extent on modifying lifestyle and eliminating factors that contribute to headache. The approach to migraine should be holistic: it should include normalizing the sleep schedule, healthy nutrition, regular physical activity and avoiding triggers. Such measures are the basis of therapy and are recommended for all patients.

• Normalizing sleep. Inadequate or irregular sleep is one of the most common migraine triggers. Both lack of sleep and excess sleep ("weekend" migraines) can provoke attacks. The patient should therefore keep a regular routine: go to bed and get up at the same time every day and sleep a sufficient number of hours (usually 7–8 for an adult). In case of insomnia, sleep hygiene measures should be taken (quiet, a dark bedroom, avoiding gadgets before bed, relaxation techniques). If necessary, melatonin at night can be used, as mentioned, or cognitive behavioral therapy for insomnia (CBT-I). It is also useful to identify and treat any sleep disorders that aggravate migraine: for example, obstructive sleep apnea (OSA) in patients who snore or are obese. Treating OSA (CPAP therapy) may reduce headache frequency (studies noted improvement in migraine with CPAP use in patients with apnea). Regular, good-quality sleep is therefore one of the "pillars" of migraine prevention.
• Diet and hydration. Although there is no single "migraine diet", nutrition matters a great deal. It is recommended to follow a healthy balanced diet and to avoid fasting and dehydration. Do not skip meals: long intervals and fluctuations in glucose levels can provoke attacks. Patients are therefore advised to eat regular small meals rich in protein, fiber and healthy fats, to avoid sharp drops in blood sugar. Identifying individual food triggers is also important: in about 10% of people, certain foods clearly provoke migraine. Typical triggers are red wine and other alcohol, aged cheeses (tyramine), chocolate, foods containing monosodium glutamate (MSG), artificial sweeteners (aspartame) and nitrates (in smoked meats). The patient should keep a food diary and, if recurring links are found, avoid the corresponding foods. At the same time, overly strict diets should be avoided: elimination diets have conflicting effectiveness and can lead to a shortage of nutrients. If elimination is done at all, it should be targeted and supervised (for example, a gluten-free diet only in people with celiac disease and migraine, which may substantially reduce headache). Some special dietary approaches have shown benefit in migraine: a diet high in omega-3 and low in omega-6 fats improves the condition (fewer and shorter attacks); a ketogenic diet, in studies of patients with obesity and migraine, led to a marked reduction in attack frequency (possibly through changes in the energy metabolism of the brain and reduced excitability). However, such diets should be used with caution and only when indicated. The general recommendation is rational nutrition: enough protein, fresh vegetables and fruit, whole grains, omega-3 sources (fish, flax), and fewer processed foods and preservatives. Hydration is also important: drink enough water throughout the day, because dehydration often provokes headache. Preferably 1.5–2 liters of fluid a day (taking into account kidney and heart conditions). Avoid excessive caffeine (more than 200–300 mg a day), since it can cause fluctuations in vascular tone and cause caffeine-withdrawal headache. A small, steady amount of caffeine is acceptable and in some people may even slightly help prevent attacks (caffeine is a component of some combination migraine medicines), but consistency matters: 1 cup of coffee every day is better than 3–4 occasionally.
• Physical activity. Regular aerobic exercise has many positive effects: it improves cardiovascular health, normalizes weight and lowers stress. For migraine, physical activity is an effective preventive measure: studies have shown that an aerobic training program (for example, 30–40 minutes of brisk walking or cycling 3 times a week) reduces attack frequency at least as much as medication. In a randomized study comparing 3 months of aerobic exercise, relaxation and topiramate, the results in the three groups were similar: migraine frequency fell by about the same amount in all of them. No group outperformed another, meaning that exercise proved as effective as drug therapy. Patients with migraine are therefore advised to do regular, measured cardio exercise. The best option is moderate-intensity aerobic exercise (which causes a moderate rise in heart rate) for at least 150 minutes a week, or about 30 minutes 5 times a week. It is important to start gradually so as not to provoke an attack through overexertion: very intense workouts can themselves become a trigger. It is best if physical activity is even and consistent. Yoga is also useful: it combines moderate physical load, muscle stretching and relaxation; several studies showed that yoga 2–3 times a week reduces migraine frequency and intensity compared with the usual routine.
• Avoiding harmful habits and other triggers. Patients with migraine are advised to stop smoking, because nicotine causes vascular fluctuations and neuroinflammatory reactions that can provoke migraine. Alcohol should also be limited, especially red wine and strong spirits; alcohol is a trigger for about 30% of patients, causing an attack on the same or the next day. During preventive treatment, an excess of pain medication should be avoided (as discussed, to prevent medication-overuse headache). Normalizing body weight has a favorable effect: obesity increases the risk of migraine becoming chronic, so with a high BMI a weight-loss program (diet + physical activity) is recommended, and even a moderate reduction in weight may reduce headache frequency.
• Daily routine and stress management. Keeping a consistent routine is key: the brain likes stability. The "SEEDS" concept (Sleep, Eat, Exercise, Diary, Stress) highlights five pillars of lifestyle in migraine: sleep, nutrition, physical exercise, keeping a diary/monitoring, and stress control. A person with migraine should keep a headache diary, noting attacks and possible triggers (stress, foods, weather, phase of the menstrual cycle and so on), which helps identify patterns and manage the situation better. Stress management is critically important: practice relaxation and meditation (as described above), eliminate chronic stressors where possible, and balance the workload. If stressful events are unavoidable, plan preventive measures (the same extra rest, timely use of an NSAID or a triptan as prevention if the doctor has recommended it, for example in menstrual migraine, the day before the expected attack). In general, a healthy lifestyle is the foundation of successful migraine treatment. Lifestyle changes have no side effects and are good for overall health, and studies indicate that they can substantially reduce the burden of migraine. As the American Headache Society notes, a stable sleep schedule, a balanced diet and regular exercise help reduce the frequency and intensity of attacks.

Conclusion: The protocol presented covers all the key aspects of modern migraine treatment, from rational drug therapy of acute attacks to personalized prevention using medications, device-based methods, supplements, psychotherapy and lifestyle changes. It is important to emphasize that the best results are achieved with a combination of approaches. For example, a patient may receive a preventive medicine (propranolol or topiramate), take magnesium and riboflavin at the same time, use a Cefaly device every evening, learn relaxation techniques and follow a healthy routine; such a multicomponent plan is science-based and may help reduce migraine frequency and improve quality of life. All recommendations should be adapted to the patient, taking into account coexisting diseases, preferences and response to treatment. Regular monitoring of effectiveness (a headache diary, MIDAS/HIT-6 assessment) helps to evaluate progress objectively. In this way, the evidence-based multidisciplinary approach to migraine applied at CSM Clinic aims to achieve good control of the condition, minimizing both the pain itself and its impact on everyday life.

Author: O. S. Kiian
Founder and Director of CSM Clinic