Chronic Migraine Management

Chronic migraine (CM) is defined as: Headache on 15 days per month for at least 3 months, and 8 of the 15 days meet the criteria for migraine.

Incidence of CM: 3.2 million migraine sufferers have CM. 2.5% of those with Episodic migraine (EM), i.e.: less than 15 days per month of headache, progress yearly to CM.

  • The headaches are not always associated with migraine features, and may resemble a mixture of migraine and tension-type headaches with intermittent severe migraine type headaches.
  • Depression is present in 80% of CM patients.
  • Risk factors for conversion from EM to CM include: medication overuse (especially opiates and barbiturate combinations), high caffeine use, female gender, stressful life events, anxiety, baseline high attack frequency, lower educational and socioeconomic levels, white race, those previously married, lifetime injuries to the head or neck, obesity, snoring, arthritis, and diabetes.
  • Only 20% of patients with CM are diagnosed correctly.
  • Only 33% of patients with CM are using preventative medications.

Medication overuse is a common cause of chronic migraine. When the medications listed below are used at the frequency stated the diagnosis is CM and possible medication overuse headache.

  • Opiates on 8 or more days per month (oxycodone, morphine, hydrocodone, etc).
  • Butalbital combinations 5 or more days per month (Fiorinal, Fiorinal with codeine).
  • Over-the-counter pain relievers such as Tylenol, Advil, Excedrin, on 10 or more days per month.
  • Triptans on 10 or more days per month, or simple analgesics, or any combination of triptans and analgesic opioids on 15 or more days per month for 3 months may result in medication overuse headache (MOH).

Treatment options for CM:

Transitional therapy options will be discussed and planned with your provider at The Headache Center. Options include:

  • Withdrawal of the overused medication and initiation of preventative medication (the overused medications must be tapered gradually to avoid complications).
  • Caffeine use limited to 200 mg per day. Some patients are even more sensitive and require further restriction
  • Anti-inflammatory medications including steroids may be helpful during the transition.
  • Long acting triptans such as Amerge (Naratriptan) or Frova (Frovatriptan) may be used.
  • Occipital and trigeminal nerve blocks with local anesthetic may be helpful
  • IV DHE (dihydroergotamine) regimen which requires hospitalization for 2-5 days may be necessary in some cases.

OnabotulinumtoxinA (Botox) is the only FDA-approved treatment for CM, approved in 2010 based upon the PREEMPT trials. Studies have shown that some patients who do not respond after the first treatment may respond after the second or third treatment given at 12 week intervals. Expense of treatment is offset by less triptan use and a reduction in migraine-related ED/hospital/urgent care visits.

Other medication options that have been studied with randomized-controlled-trials and shown beneficial in CM include Topamax (topiramate), Elavil (amitriptyline), Neurontin (gabapentin), and tizanidine (Zanaflex). Open-label trials of Lyrica (pregabalin), Zonegren (zonismide), and Namenda (memantine) indicate these may also provide some benefit.

Alternative complementary treatments have not been demonstrated in studies to be effective for CM.

However, the following options could be considered:

  • Behavioral sleep modification, relaxation therapy, physical exercise.
  • Magnesium oxide 500 mg a day and Petadolex 150 mg a day.
  • Weight loss even with Bariatric surgery might provide some benefit.
  • Occipital and Trigeminal nerve stimulation for CM still being assessed.

Prognosis of CM:

  • Of 383 patients with self-reported CM, 26% had remitted CM over 2 years (defined as fewer than 10 headache days per month). Predictors included:
    • Lower baseline headache frequency (less days per month)
    • Absence of allodynia (painful sensitivity of the scalp)
  • 136 patients with CM – presenting to specialty headache clinic follow for 1 year, 70% reverted to episodic migraine. Predictor of reversion:
    • Complete withdrawal of overused medications
    • Compliance with preventive medication treatments
    • Regular physical exercise

Presented by Phyllis Taylor, NP to Headache Journal Club 7/8/13

Evans, Randolph, MD, A Rational Approach to the Management of Chronic Migraine, Headache 2013; 53: 168-176

Schulman EA, Lake AE III, Goadsby PJ, Peterlin B,et al. Defining refractory migraine and refractory chronic migraine: Proposed criteria. Headache. June 2008. 48: 778-782.