Which community health resource can best meet the needs of a person with chronic migraines?

• Overview
• Symptoms and Causes
• Diagnosis and Tests
• Management and Treatment
• Prevention
• Outlook / Prognosis
• Resources

Overview

What is chronic migraine?

Chronic migraine is defined as having at least 15 headache days a month, with at least 8 days of having headaches with migraine features, for more than 3 months. Chronic headache begins as less frequent headache episodes that gradually change into a more frequent headache pattern.

Who gets chronic migraine?

Chronic migraine affects between 3 and 5 percent of people in the United States. Approximately 3 percent of people who have episodic migraine transform to chronic migraine each year.

Symptoms and Causes

What causes chronic migraine?

Chronic migraine develops over time due to a number of factors:

• The number of episodic headaches steadily increases over time.
• Medications once used to treat episodes of headache become overused in an attempt to keep the increased number of headaches under control. Barbiturate-containing medications (amobarbital [Amytal®], butabarbital [Butisol®]) and narcotics (opioids/opiates) are the reported prescription drugs that lead to developing chronic headache. The most common drugs responsible for medication overuse headaches are the over-the-counter medications, such as Excedrin® and generic equivalents, the non-steroidal anti-inflammatory medications, and acetaminophen (Tylenol®).

Other factors associated with chronic migraine include:

• Obesity
• Snoring
• Mood disorders, especially anxiety and depression
• Ongoing disrupted sleep pattern
• Excessive caffeine intake
• History of severe emotional (stressful life events) or physical trauma

What are the symptoms of chronic migraine?

Symptoms of episodic migraine and chronic migraine are the same. The difference is simply the increase in frequency of the number of headaches. Typical migraine symptoms include:

• Head pain that is moderate to severe in intensity, worsened by physical activity/movement
• Pain on one or both sides of the head
• Throbbing pain or pressure-like pain
• Sensitivity to light, sound, smells
• Nausea/vomiting
• Dizziness

Signs an episodic migraine is transforming to a chronic migraine include:

• Having a growing number of migraine attacks
• Taking more medication because of the growing number of attacks

Diagnosis and Tests

How is chronic migraine diagnosed?

Your doctor will take a detailed medical history. The doctor will ask about:

• Your pattern of migraine pain, including when and how migraines begin; if they are episodic or continuous; how long the migraine lasts; if there are any triggers or factors that make the migraine worse.
• Your description of the pain, including its location, sensation, and severity.
• Other symptoms that accompany the pain, such as auras, lack of energy, stiff neck, dizziness, changes in vision or in senses, and nausea/vomiting.
• Your current and previously tried treatments, including when the medications are taken, dosages, outcome and side effects and use of alternative or complementary therapies.
• Your medical history including other health problems (especially sleep problems, depression, anxiety or fibromyalgia), family history of headache, current non-headache medications, and lifestyle choices (smoker, alcohol consumption, caffeine intake).

Management and Treatment

How is chronic migraine treated?

Treatment of chronic migraine is focused on managing lifestyle choices and headache triggers, managing migraine attacks and providing preventive treatments to reduce migraine attacks.

Lifestyle changes include:

• Losing weight if you are overweight.
• Beginning an exercise plan that has been approved by your doctor.
• Managing your stress. Learn techniques to control stress such as meditation, yoga, relaxation training, or mindful breathing.
• Developing a routine regimen regarding meal and snack times; do not skip meals.
• Staying well hydrated.
• Beginning treatment for any existing mood disorder (including depression and anxiety) or sleep problem.

The typical treatment plan for managing migraine attacks includes:

• Treating migraine attacks early when pain in mild; begin with a simple pain killer (paracetamol, aspirin, ibuprofen, naproxen) and slowly increase the dose as needed to the max tolerated dose, unless the headache is severe at the start or will become severe. In such cases add a triptan to the above medication to improve efficacy. Avoid use of opiates if possible. Your doctor will devise a treatment plan to avoid worsening chronic headache by overusing medications.
• Treat associated side effects, such as nausea.
• Consider other treatment techniques, including transcranial magnetic stimulation and transcutaneous supraorbital nerve stimulation.

Preventive treatment is aimed at reducing the number of headaches. Preventive treatments include:

• Beta blockers, such as propranolol (Inderal®), atenolol (Tenormin®) and metoprolol (Lopressor®)
• Angiotensin blockers, such as candesartan (Atacand®)
• Tricyclic antidepressants, such as nortriptyline (Pamelor®), amitriptyline (Elavil®)
• Anticonvulsants, such as topiramate (Topimax®), sodium valproate
• Flunarizine (Sibelium®)
• Onabotulinum toxin A (Botox®) injections
• Calcitonin gene-related peptide (CGRP), such as galcanezumab (Emgality®), fremanezumab (Ajovy®), erenumab (Aimovig®)

Prevention

Can chronic migraine be prevented?

Keep a daily headache diary. As soon as you notice an increase in the number of headaches you are having, see your headache specialist. Do not wait until your headaches become a daily occurrence to seek help. It is easier to halt and reverse chronic migraine if caught early.

Look at the risk factors and modify those you can (see lifestyle changes above).

Outlook / Prognosis

What’s the outlook for people with chronic migraine?

The hope for people with chronic migraine is to control the headache. With a good treatment plan, it is reasonable to believe that the number and severity of migraine headaches can be reduced. Many patients with chronic migraine may revert to episodes of migraine over time.

For patients with chronic migraines that have not responded to previous treatments, there are other options. Some patients need more aggressive hands-on techniques such as nerve blocks and trigger point injections. Other patients – particularly those with medication overuse headaches - need to rid their body of previous medications (be detoxified) in a monitored setting, such as an infusion suite. In the infusion suite, patients receive intravenous medications that stop migraines and treat the nausea and vomiting.

For patients with the most difficult migraines to treat – those not responding to any treatments, in whom detoxification efforts have not been totally effective, and patients are still using medications not helpful to improving their headache – a team approach is required. The team, consisting of healthcare professionals from neurology, psychiatry, psychology, nursing, physical therapy and social work, meet together with the patient and the patient’s family over a series of weeks to develop a plan of care and monitor progress. Patients with difficult to treat migraines should ask their doctors to refer them to facilities that offer such multi-team, patient-centered programs.

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