Treatment Options for Chronic Migraine
For chronic migraine, the most effective evidence-based treatment options include topiramate, onabotulinumtoxinA (Botox), and CGRP monoclonal antibodies, with topiramate recommended as first-line therapy due to its proven efficacy and lower cost. 1
Definition and Diagnosis
Chronic migraine is defined as:
- Headaches occurring on ≥15 days per month for at least 3 months
- With migraine features present on ≥8 days per month 1
- Not attributable to another cause
A headache diary is essential for accurate diagnosis, as patients may underreport milder headache days 1.
Treatment Algorithm
First-Line Preventive Therapy:
- Topiramate:
- Starting dose: 25mg daily
- Gradually titrate to target dose of 100mg daily (can range from 50-200mg based on patient response)
- Proven effective in randomized controlled trials specifically for chronic migraine 1, 2
- Common side effects: paresthesia (53%), nausea (9%), dizziness (6%), fatigue (6%), cognitive issues 2
Second-Line Preventive Therapies:
OnabotulinumtoxinA (Botox):
- Only FDA-approved therapy specifically for chronic migraine prophylaxis 1, 3
- Administered by headache specialists using standardized injection protocol
- Warning: Monitor for swallowing or breathing problems, which can occur hours to weeks after injection 3
- Typically reserved for patients who have failed at least 2-3 other preventive medications due to regulatory restrictions 1
CGRP Monoclonal Antibodies (erenumab, fremanezumab, galcanezumab):
- Proven beneficial for patients who failed at least two other preventive medications 1
- Typically reserved as third-line due to cost and access issues
Acute Treatment for Breakthrough Headaches:
First-line: NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
- Take early in the attack while pain is still mild
Second-line: Triptans (e.g., sumatriptan) 1
Managing Medication Overuse Headache (MOH)
MOH is common in chronic migraine patients (up to 78% in some studies) 2:
- Defined as headache occurring ≥15 days/month due to regular overuse of acute headache medication 1
- Management requires withdrawal of overused medication
- Abrupt withdrawal is preferred (except for opioids) 1
- Preventive therapy can be started concurrently with withdrawal or upon re-emergence of headache 1
Addressing Comorbidities
Identify and manage common comorbidities that can affect treatment outcomes 1, 5:
- Depression/anxiety: Consider amitriptyline as preventive therapy
- Sleep disorders: Improve sleep hygiene, consider amitriptyline
- Obesity: Topiramate may be preferred (associated with weight loss)
- Stress: Incorporate stress management techniques
Non-Pharmacological Approaches
Incorporate these strategies alongside medication 1, 5:
- Stress management techniques
- Regular sleep schedule
- Regular meals and hydration
- Moderate exercise (at least 40 minutes, three times weekly)
- Identification and avoidance of triggers when possible
Treatment Monitoring and Follow-up
- Use headache calendars to track frequency, severity, and medication use
- Evaluate effectiveness after 2-3 months of consistent treatment
- Set realistic expectations: goal is significant reduction in headache frequency/severity, not complete elimination
- Long-term management typically returns to primary care after specialist consultation 1
Important Caveats
- Avoid opioids for migraine management due to high risk of medication overuse and dependence
- Limit acute medications to <2 days per week to prevent medication overuse headache 1, 4
- Recognize that chronic migraine treatment is typically long-term, not short-term
- Consider referral to headache specialist for patients with refractory symptoms 1