What is the approach to managing chronic migraines?

Management of Chronic Migraines

For chronic migraine management, first rule out medication overuse headache, then initiate preventive therapy with topiramate as first-line treatment, followed by onabotulinumtoxinA or CGRP monoclonal antibodies if topiramate fails, while addressing lifestyle factors and comorbidities. 1, 2

Initial Assessment and Diagnosis

• Chronic migraine is defined as headaches occurring on ≥15 days per month for at least 3 months, with migraine features on ≥8 days per month 1
• Key assessment elements:
  • Headache frequency, intensity, and duration
  • Medication use patterns to identify medication overuse headache (MOH)
  • Presence of comorbidities (depression, anxiety, sleep disorders, obesity)
  • Current lifestyle factors and triggers

Step 1: Rule Out Medication Overuse Headache

MOH frequently mimics chronic migraine and must be addressed first:

• Defined as headache occurring ≥15 days/month due to regular overuse of acute medications:
  • Simple analgesics used >15 days/month
  • Triptans or combination analgesics used >10 days/month 2
• Management approach:
  • Patient education about MOH is essential 1
  • Abrupt withdrawal of overused medication (except for opioids, which require gradual tapering) 1
  • Warning: withdrawal typically causes temporary worsening before improvement 1

Step 2: Implement Preventive Therapy

After ruling out MOH, initiate preventive medication:

First-line treatment:

• Topiramate (100 mg/day) - strongest evidence for chronic migraine 1, 2
  • Advantages: may lead to weight loss, which is beneficial as obesity is a risk factor 2
  • Monitor for cognitive side effects

Second-line treatments (if topiramate fails or is contraindicated):

• OnabotulinumtoxinA - FDA-approved specifically for chronic migraine 1, 3

  • Administered as multiple injections every 12 weeks
  • Warning: monitor for potential adverse effects including swallowing/breathing problems 3

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1

  • Indicated when at least two other preventive medications have failed
  • Newer treatment option with favorable side effect profile

Other preventive options with less robust evidence for chronic migraine:

• Beta blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day) 2
• Amitriptyline (30-150 mg/day) - particularly useful if comorbid depression or sleep disturbances 2
• Divalproex sodium (500-1500 mg/day) 2

Step 3: Address Lifestyle Factors and Triggers

Implement comprehensive lifestyle modifications:

• Regular sleep schedule
• Consistent meal times and adequate hydration
• Regular exercise program (aerobic exercise 40 minutes, three times weekly) 2
• Stress management (yoga, cognitive-behavioral therapy, mindfulness) 2
• Limited caffeine intake 2

Step 4: Manage Comorbidities

Addressing comorbid conditions improves treatment outcomes:

• Depression and anxiety: consider amitriptyline if present
• Sleep disorders: improve sleep hygiene, consider amitriptyline
• Obesity: encourage weight loss, consider topiramate
• Chronic pain conditions: address with appropriate therapies 1

Step 5: Acute Treatment Strategy

Even with preventive therapy, patients need effective acute treatment:

• NSAIDs (aspirin 650-1000 mg, ibuprofen, naproxen) for mild attacks 2
• Triptans for moderate-severe attacks 2
• Combination of triptan + NSAID for optimal efficacy 2
• Antiemetics for attacks with prominent nausea/vomiting 2

Step 6: Monitoring and Follow-up

• Use headache diary to track:
  • Frequency and severity of attacks
  • Medication use and efficacy
  • Potential triggers 2
• Evaluate treatment effectiveness after 2-3 months 2
• Consider treatment modification if inadequate response
• Preventive treatment should continue for at least 3-4 months to determine efficacy 2

When to Refer to Specialist Care

Referral to neurology/headache specialist is indicated when:

• Diagnosis is uncertain
• Treatment is ineffective despite appropriate interventions
• Significant comorbidities complicate management
• Medication overuse cannot be managed in primary care 1, 2

Common Pitfalls to Avoid

1. Failing to identify and address medication overuse headache
2. Inadequate duration of preventive therapy (minimum 3-4 months needed)
3. Not addressing lifestyle factors and triggers
4. Overlooking important comorbidities
5. Not using headache diaries to monitor treatment response
6. Premature discontinuation of preventive therapy