The amount of sleep, the quality of sleep, and having a consistent sleep schedule when possible are all important, particularly in managing headaches. Aim for consistency in sleep patterns, the time of going to sleep and waking, even at weekends. Sleeping or lying in too long past the usual time may lead to a higher likelihood of migraines occurring. Most adults need around eight hours of sleep per night. Exercise can be helpful, though if vigorous this is ideally undertaken before dinner, rather than later in the evening, due to the stimulating effect.

It is sensible to avoid using the bed/bedroom for activities that could be done elsewhere (such as using electronics, watching TV, studying). Try to avoid staying in bed if you are wide-awake. This approach helps to maximise the mind’s association of the bedroom primarily with rest and sleep. Avoid smoking if possible as nicotine has a stimulating effect on the brain and also suppresses melatonin levels. Avoiding caffeine in the evening is recommended, as this can affect both the time taken to get to sleep and the quality of it. Bear in mind that as well as the obvious culprits such as tea and coffee, many soft drinks and certain chocolates can be high in caffeine. Be mindful that alcohol may also reduce the quality of sleep.

Consistency of sleep can be more difficult to achieve with long-distance travel, but improving other factors, such as those described below, may help to at least partly compensate for this. Listening to relaxing music or meditation audio before going to bed may be very helpful for some people. There is a growing evidence base for the use of cognitive behavioural therapy for insomnia (CBTi). https://freecbti.com is a freely accessible option. The NHS inform ‘Sleep problems and insomnia’ online guide is also recommended.

Irregular intake of food, such as with skipped meals, can cause the blood sugar to fluctuate too much, making migraines more likely. Ideally avoid skipping meals, including breakfast. One way to address this is to eat carbohydrates little but often. Some people find that eating something ‘low GI’ at bedtime (such as a banana) can also be helpful to stabilise blood sugar levels overnight. Be cautious around the consumption of refined sugary foods such as sweets/energy drinks, which may lead to a quick rise in blood sugar followed by a rapid fall.

Fasting or having significant variation in calorie intake on different days of the week, as certain diet approaches advocate, may trigger migraines for some. It is commonly believed that certain foods, such as cheese or chocolate, or even environmental factors such as bright light, trigger migraines. Research in this area actually points away from these being triggers and instead being part of the warning phase of migraine, before the headache starts, with a craving for a particular food and light sensitivity being a symptom.

Similar to food intake, the brain prefers reasonably steady levels of hydration, with fluid intake spaced steadily throughout the day. Keeping a bottle of water with you may help.

Alcohol may make it more likely for a migraine to occur the following day. In individuals with cluster headache who are within a bout, alcohol ingestion will tend to trigger an attack over the subsequent hour or two.

Regular exercise is well regarded as being beneficial for body and mind, however, unaccustomed exercise may be a trigger for some individuals to have a migraine. Moderate aerobic exercise, lasting 30 minutes at a time, three to ideally five times each week, can help reduce stress and maintain physical fitness levels. Measures that can be helpful to reduce the likelihood of migraine occurring include warming up sufficiently, adequate hydration, and eating at least an hour and a half before exercise, to try to counteract fluctuations in blood sugar. Fast acting sugary sweets/tablets, or a sweet drink, during exercise can help maintain sugar levels.

Migraines can potentially be a disruptive and unpredictable condition, causing difficulty in functioning productively at times, impacting on the ability to work and learn. The Migraine Trust offer a helpful guide to help you in discussions with your place of work or education around ways they may be able to support you.

Some patients may wish to try an over the counter supplement as part of the approach to managing their migraines. These may be sourced from reputable health food shops or online stores. The doses required here are generally higher than those contained within multivitamins – the necessary Riboflavin dose being around 30 times higher than in typical Vitamin B complex multivitamins. Similar to prescribed migraine preventatives, it may take 8-12 weeks before the effectiveness of a supplement is apparent. The following agents can be taken alone, combined, or taken in combination with prescribed migraine preventatives if desired:

• Riboflavin (Vitamin B2) 400mg once daily
• CoEnzyme Q10 (a Vitamin-like substance) 150mg daily

Although there is no evidence that these treatments cause developmental problems it is recommended that these supplements are not used during pregnancy, or when trying to conceive.

It is also worth highlighting that the use of any painkiller, on too many days per month over a number of months, may cause migraine control to be worse, and for migraines to be poorly responsive to what may otherwise be effective preventatives. Advice around this can be found on the NHS Forth Valley headache diary.

Topiramate (brand name Topamax®) was originally developed as a medication to control epilepsy, however, it is now mainly used as an effective treatment for the prevention of migraines.

Unfortunately, as topiramate use during pregnancy is known to increase the risk of developmental abnormalities in the developing foetus, very careful precautions are required in females with childbearing potential. Potential developmental abnormalities include cleft lip and palate, as well as growth restriction. Rates of developmental abnormality increase seven-fold in babies born to mothers taking topiramate.

Topiramate decreases the effectiveness of some contraceptives

Topiramate may also reduce the effectiveness of some contraceptives. As such, the use of topiramate is not recommended if the only acceptable method of contraception for a patient is the combined oral contraceptive pill (COCP), the progesterone only pill (POP, “the mini-pill”), or the progesterone only implant (e.g. Nexplanon®, “the implant”).

Suitable contraceptives when taking topiramate

Topiramate can be used by women using the intrauterine (coil-type) methods of contraception, which are not weakened by topiramate. Coil-type contraception methods (e.g. Mirena, copper coil), with a failure rate of less than 1% with typical use, are regarded as being ‘highly effective’. Topiramate may also be used by women who have previously undergone sterilisation, or who have a male partner with a confirmed successful vasectomy.

The Depot Medroxyprogesteone Acetate (Depo) jag is also a contraceptive available. Brand names for this method include Depo-Provera® and Sayana-Press®. This contraceptive option is also not affected by the weakening effect of topiramate, however, the failure rate is around 6% and as such it is not considered a ‘highly effective’ contraceptive method. Depo used alongside condoms could be considered in certain circumstances, after discussion with a clinician. As barrier methods, such as condoms, are not ‘highly effective’, they cannot be used as the only contraceptive approach alongside topiramate.

Referral to Neurology for an alternative migraine treatment will be required if there are no other suitable migraine preventatives.

A PDF version of this advice is also available. Advice due to be reviewed 10/08/2025.