Table of Contents
- Introduction
- Epidemiology
- Pathophysiology
- Etiology and Risk Factors
- Diagnostic Criteria
- Differential Diagnosis
- Figure 1A: Classification per Headache Frequency
- Figure 1B: Classification per Duration of Individual Headaches
- Treatment and Management
- Risk factor avoidance is important. This includes;
- Acute management
- Complications
- Prognosis
- Conclusion
- Further Reading
- Bibliography
Primary Category
Headache & Pain
P-Category
Secondary Category
S-Category
Introduction
- 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.
Epidemiology
- 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.
Pathophysiology
- 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
Figure 1B: Classification per Duration of Individual Headaches
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
- Diphenoxylate with Atropine (Oral)
- 1 Tablet given 4 times per day or as needed for diarrhea.
- Use for 3 days.
- Promethazine (Intravenous)
- 25mg Intravenous.
- Repeated 8 hourly.
- It should be given 10 minutes prior to DHE.
- DHE (Intravenous)
- Give 1mg intravenous.
- Repeated every 8 hours.
- Use for 3 days.
- Normal Saline
- Determined by the prescriber.
- Heart disease
- Stroke
- Previous allergic reaction
- Uncontrolled Hypertension
- Renal Failure
- Basilar Migraine
- Hemiplegic Migraine
- Within 24 hours of receiving triptan therapy
DHE Protocol
❌ Contraindicated in the following:
Complications
- Migrainous infarction
- Persistent aura without infarction
- Migraine aura-triggered seizures
Prognosis
- 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
Conclusion
- 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: Epidemiology, Mechanisms, and Treatment. In: Chronic Headache. Springer, Cham. https://doi.org/10.1007/978-3-319-91491-6_4
- Chronic migraine. BMJ, 348(mar24 5), g1416–g1416. doi:10.1136/bmj.g1416
Bibliography
- 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.
- Chronic Migraine: Epidemiology and Disease Burden. Current Pain and Headache Reports, 15(1), 70–78. doi:10.1007/s11916-010-0157-z
- Chronic Migraine: Epidemiology, Mechanisms, and Treatment. Chronic Headache. Springer, Cham. https://doi.org/10.1007/978-3-319-91491-6_4
- Your Resource for Headache Info | American Headache Society. https://americanheadachesociety.org/wp-content/uploads/2018/05/CMinforgraphicPosterWEBzoom.pdf
- Global prevalence of chronic migraine: A systematic review. Cephalalgia, 30(5), 599–609. doi:10.1111/j.1468-2982.2009.01941.x
- Spectrum of illness: Understanding biological patterns and relationships in chronic migraine. Neurology, 72(Issue 5, Supplement 1), S8–S13. doi:10.1212/wnl.0b013e31819749
- Chronic migraine. BMJ, 348(mar24 5), g1416–g1416. doi:10.1136/bmj.g1416
- The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 33(9), 629–808. doi:10.1177/0333102413485658
- Chronic migraine: risk factors, mechanisms and treatment. Nature Reviews Neurology, 12(8), 455–464. doi:10.1038/nrneurol.2016.93)
- 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.
- Chronic migraine: Symptoms, causes, treatments. (n.d.). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/9638-chronic-migraine#management-and-treatment
- Chronic migraine. (2021, June 3). The Migraine Trust. https://migrainetrust.org/understand-migraine/types-of-migraine/chronic-migraine/#page-section-7
- Calcitonin gene-related peptide (CGRP) receptor antagonists in the treatment of migraine. CNS drugs vol. 24,7 (2010): 539-48.
- 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
Archive
Preventive management
Pharmacological
- 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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