Chronic Migraine Headache

It is a type of headache that occurs on ≥15 days per month for more than 3 months, and has the features of migraine on at least 8 days per month

Primary Category
Headache & Pain
Secondary Category


  • Sometimes referred to as transformed migraine.
  • It evolves from episodic migraine.
  • It is a type of headache that occurs on ≥15 days per month for more than 3 months, and has the features of migraine on at least 8 days per month.


  • Overall prevalence of chronic migraine among the general population is 0.9 to 2.2%.
  • Approximately 2.5% of patients with episodic migraine develop chronic migraine.
  • Chronic migraine is 2-3 times more common in women than men in the US.
  • 1.3% women and 0.5% men meet the criteria for chronic migraine in the US.


  • Exact mechanism is not known.
  • Associated with
    • Persistently increased cortical excitability
    • Central desensitization
    • Alteration in nociceptive signaling
    • Reduced cortical inhibition
  • Functional and structural abnormalities involving Periaqueductal Gray Matter can be associated with chronic migraine.
  • Impairment of cortical processing of sensory stimuli is also implicated.

Etiology and Risk Factors

  • The factors associated with transformation of episodic migraine into chronic migraine include
    • Obesity
    • Snoring
    • Sleep disorders
    • Excessive caffeine intake
    • Psychiatric disease; depression doubles the risk of developing chronic migraine.
    • High baseline headache frequency
    • Overuse of migraine abortive drugs
    • Major life changes
    • Head or neck injury
    • Cutaneous allodynia
    • Female sex
    • Comorbid pain disorders
    • Lower socioeconomic status

Diagnostic Criteria

International Classification of Headache Disorders (ICHD-3) Diagnostic Criteria for Chronic Migraine
Criteria A
  • Headache (tension-type-like and/or migraine-like)
  • 15 days per month for >3 months
  • and fulfilling criteria B and C
Criteria B
  • Occurring in a patient who has had at least five attacks fulfilling criteria Migraine without aura and/or Migraine with aura
Criteria C
  • On 8 days per month for >3 months, fulfilling any of the following:
    • Criteria C and D for Migraine without aura (refer to chapter; Types of headache)
    • Criteria B and C for Migraine with aura (refer to chapter; Types of headache)
    • Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
Criteria D
  • Not better accounted for by another ICHD-3 diagnosis.
Source: Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. PMID: 23771276.

Differential Diagnosis

  • Hemicrania continua; daily, continuous, one-sided headache that is responsive to indomethacin.
  • Chronic tension-type headache
  • New daily persistent headache

Figure 1A: Classification per Headache Frequency

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Figure 1B: Classification per Duration of Individual Headaches

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Treatment and Management

  • The identification and treatment of the comorbid conditions improve the outcome in chronic migraine.
  • They include;
    • Sleep disorders
    • Chronic pain disorders
    • Depression
    • Anxiety
    • Cerebrovascular disorders
    • Cardiovascular disorders

Risk factor avoidance is important. This includes;

  • Weight loss with a regular exercise routine
  • Caffeine restriction
  • Decreased alcohol consumption
  • Relaxation and stress avoidance
  • Modifying the response to stressors
  • Good sleep hygiene
  • Avoiding overuse of migraine abortive drugs
  • Form and maintain a daily headache diary to help identify migraine triggers and avoid them.

Acute management

  • Should be initiated as soon as the headache starts. Should not be repeated more than 2 times per week. Includes;
    • NSAIDs
    • Dopamine antagonists
    • Triptans
    • Ergotamine
    • 📢
      DHE Protocol
      1. Diphenoxylate with Atropine (Oral)
        1. 1 Tablet given 4 times per day or as needed for diarrhea.
        2. Use for 3 days.
      1. Promethazine (Intravenous)
        1. 25mg Intravenous.
        2. Repeated 8 hourly.
        3. It should be given 10 minutes prior to DHE.
      1. DHE (Intravenous)
        1. Give 1mg intravenous.
        2. Repeated every 8 hours.
        3. Use for 3 days.
      1. Normal Saline
        1. Determined by the prescriber.

      Contraindicated in the following:
      • Heart disease
      • Stroke
      • Previous allergic reaction
      • Uncontrolled Hypertension
      • Renal Failure
      • Basilar Migraine
      • Hemiplegic Migraine
      • Within 24 hours of receiving triptan therapy


  • Migrainous infarction
  • Persistent aura without infarction
  • Migraine aura-triggered seizures


  • Many patients with chronic migraine revert back to episodes of migraine with the following;
    • Good compliance to migraine abortive drugs
    • Decreased headache frequency at baseline
    • Absence of cutaneous allodynia
    • Physical exercise
    • Withdrawal of overused migraine abortive drugs


  • Chronic Migraine is a debilitating condition.
  • Living with it is associated with significant unwanted negative stigma.
  • It causes immense financial and economic burden on the individual.
  • Decreases the workplace productivity and increases absence from work and school.
  • It is also associated with high disease burden, more severe psychiatric comorbidities and excessive use of healthcare facilities.

Further Reading

  • Chronic migraine. BMJ, 348(mar24 5), g1416–g1416. doi:10.1136/bmj.g1416


  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. doi: 10.1177/0333102413485658. PMID: 23771276.
  1. Chronic Migraine: Epidemiology and Disease Burden. Current Pain and Headache Reports, 15(1), 70–78. doi:10.1007/s11916-010-0157-z
  1. Chronic Migraine: Epidemiology, Mechanisms, and Treatment. Chronic Headache. Springer, Cham.
  1. Your Resource for Headache Info | American Headache Society.
  1. Global prevalence of chronic migraine: A systematic review. Cephalalgia, 30(5), 599–609. doi:10.1111/j.1468-2982.2009.01941.x
  1. Spectrum of illness: Understanding biological patterns and relationships in chronic migraine. Neurology, 72(Issue 5, Supplement 1), S8–S13. doi:10.1212/wnl.0b013e31819749
  1. Chronic migraine. BMJ, 348(mar24 5), g1416–g1416. doi:10.1136/bmj.g1416
  1. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 33(9), 629–808. doi:10.1177/0333102413485658
  1. Chronic migraine: risk factors, mechanisms and treatment. Nature Reviews Neurology, 12(8), 455–464. doi:10.1038/nrneurol.2016.93)
  1. Treatment of acute migraine headache. Am Fam Physician. 2011 Feb 1;83(3):271-80. Erratum in: Am Fam Physician. 2011 Oct 1;84(7):738. PMID: 21302868.
  1. Chronic migraine: Symptoms, causes, treatments. (n.d.). Cleveland Clinic.
  1. Chronic migraine. (2021, June 3). The Migraine Trust.
  1. Calcitonin gene-related peptide (CGRP) receptor antagonists in the treatment of migraine. CNS drugs vol. 24,7 (2010): 539-48.
  1. Non Medication, Alternative, and Complementary Treatments for Migraine. Headache p. 796-806. August 2012, Vol.18, No.4. doi: 10.1212/01.CON.0000418643.24408.40

Preventive management


  • Beta-blockers
    • Propranolol
    • Timolol
    • Atenolol
    • Metoprolol
  • Anticonvulsants
    • Topiramate
    • Sodium Valproate
    • Gabapentin
  • Antidepressants
    • Nortriptyline
    • Amitriptyline
  • Calcium Channel Blocker
    • Flunarizine
  • Botox (Onabutolinum toxin A) injection
  • Calcitonin-gene related peptide, CGPR, Antagonists
    • Galcanezumab
    • Fremanezumab
    • Erenumab
  • Greater Occipital Nerve Blocks

Non pharmacological

  • Dietary supplements may help reduce migraine headaches. They include,
    • Coenzyme q10
    • Magnesium
    • Vitamin B-12
    • Butterbur (Coltsfoots)
    • Physical therapy
    • Behavioral therapy
    • Relaxation techniques
    • Biofeedback methods
    • Cognitive behavioral therapy
    • Massage
    • Acupuncture
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Muhammad Umair MD

ECFMG Certified. Research Associate at NeuroCare.AI Academy

Muhammad Roshan Asghar MD

ECFMG Certified. Research Fellow at NeuroCare.AI Academy and Postdoc Intern at Global Innervation LLC.

Junaid Kalia MD

Written by

Junaid Kalia MD

Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy

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