Chronic Migraine Headache

Authors:

Muhammad Umair MD,

Muhammad Roshan Asghar MD

Junaid Kalia MD

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

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
📢
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.
2. Promethazine (Intravenous)
1. 25mg Intravenous.
2. Repeated 8 hourly.
3. It should be given 10 minutes prior to DHE.
3. DHE (Intravenous)
1. Give 1mg intravenous.
2. Repeated every 8 hours.
3. Use for 3 days.
4. 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

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

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