What is the workup and management plan for chronic migraines?

Workup and Management of Chronic Migraines

The comprehensive workup for chronic migraines should include ruling out secondary causes of headache, making an accurate diagnosis, and establishing a multidisciplinary management plan that includes both pharmacological and non-pharmacological approaches.

Diagnosis and Initial Workup

Definition and Diagnostic Criteria

• Chronic migraine: ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria 1
• Key diagnostic features:
  • Headache attacks lasting 4-72 hours (untreated)
  • At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by physical activity
  • At least one of: nausea/vomiting, photophobia and phonophobia

Essential Workup Components

1. Rule out secondary causes of headache

   • Detailed headache history
   • Neurological examination
   • Consider neuroimaging if "red flags" present

2. Headache diary implementation

   • Document frequency, duration, intensity, and associated symptoms
   • Identify potential triggers and medication use patterns
   • Use validated tools like HIT-6 or MSQ to assess impact 1

3. Medication overuse assessment

   • Screen for use of acute headache medications ≥10 days/month
   • Common culprits: triptans, NSAIDs, combination analgesics

4. Comorbidity evaluation

   • Screen for depression, anxiety, sleep disorders, obesity
   • Assess for other chronic pain conditions

Management Plan

Step 1: Address Medication Overuse

• If medication overuse headache (MOH) is present, withdrawal of overused medication is necessary
• Abrupt withdrawal is preferred for most medications (except opioids) 1
• Educate patients about temporary worsening before improvement

Step 2: Preventive Pharmacological Treatment

First-line options:

• Topiramate: Evidence-based for chronic migraine, typically 100mg daily 1

  • Monitor for cognitive effects, paresthesia, weight loss
  • Contraindicated in pregnancy

• OnabotulinumtoxinA (Botox): FDA-approved for chronic migraine 1, 2

  • 155 units administered according to PREEMPT protocol
  • Administered every 12 weeks
  • Monitor for neck pain, muscle weakness
  • Contraindicated in neuromuscular disorders

• CGRP monoclonal antibodies: Effective when other preventives have failed 1

  • Options include erenumab, fremanezumab, galcanezumab
  • Generally well-tolerated with minimal side effects
  • Limited by cost and insurance coverage

Second-line options:

• Beta-blockers (propranolol, metoprolol)
• Amitriptyline (particularly useful with comorbid depression or sleep issues)
• Venlafaxine
• Candesartan

Step 3: Acute Treatment Optimization

• Triptans (e.g., sumatriptan) 3

  • Contraindicated in cardiovascular disease, uncontrolled hypertension
  • Limit use to <10 days/month to prevent medication overuse headache

• NSAIDs

  • For mild-moderate attacks or in combination with triptans
  • Monitor for gastrointestinal and renal effects

• Antiemetics

  • For associated nausea/vomiting

Step 4: Non-Pharmacological Approaches

• Trigger identification and management 4

  • Common triggers: stress, sleep disturbances, certain foods, hormonal changes
  • Use headache diary to identify patterns

• Lifestyle modifications

  • Regular sleep schedule
  • Regular meals
  • Hydration
  • Regular exercise (40 minutes, three times weekly) 1

• Behavioral treatments

  • Cognitive behavioral therapy
  • Relaxation training
  • Biofeedback
  • Stress management

• Complementary approaches

  • Acupuncture
  • Dietary supplements (riboflavin, coenzyme Q10, magnesium) 4

Follow-up and Monitoring

Evaluation of Treatment Response

• Use headache diary to monitor frequency and severity
• Assess treatment efficacy after 2-3 months of preventive therapy 1
• Evaluate medication adherence and side effects

Specialist Referral Indications

• Diagnostic uncertainty
• Treatment resistance (failure of ≥2 preventive medications)
• Complex comorbidities
• Medication overuse that cannot be managed in primary care
• Need for specialized treatments like onabotulinumtoxinA 5

Long-term Management

• Regular follow-up every 6-12 months once stable
• Adjust treatment based on changes in headache pattern
• Consider gradual taper of preventive medication after 6-12 months of good control

Important Considerations and Pitfalls

• Avoid medication overuse: Limit acute medications to <10 days/month
• Set realistic expectations: Complete elimination of headaches is rarely achievable
• Address comorbidities: Treatment of depression, anxiety, and sleep disorders can improve migraine outcomes
• Patient education: Emphasize that chronic migraine is a neurological disorder with biological basis
• Multidisciplinary approach: Combination of pharmacological and non-pharmacological treatments is more effective than either alone 6, 4

Remember that chronic migraine management is a long-term process requiring ongoing monitoring and adjustment of treatment strategies based on patient response and tolerability.