What are the treatment options for chronic migraines?

Treatment Options for Chronic Migraines

For chronic migraine, evidence-based preventive treatments include topiramate as first-line therapy, followed by onabotulinumtoxinA (Botox) and CGRP monoclonal antibodies as second/third-line options when initial treatments fail. 1

First-Line Preventive Therapy

• Topiramate is the first-line medication of choice for chronic migraine due to its proven efficacy and lower cost compared to other options 1
• Typical dosing of topiramate should be titrated gradually (25 mg weekly) to a target dose of 100 mg/day, with flexibility from 50-200 mg/day based on patient response and tolerability 2
• Topiramate significantly reduces monthly migraine days (average reduction of 3.5 days per month compared to placebo) 2
• Common side effects include paresthesia (53%), nausea (9%), dizziness, dyspepsia, fatigue, anorexia, and attention disturbances 2
• Topiramate may be particularly beneficial for patients with obesity due to its association with weight loss 1

Second-Line and Third-Line Options

• OnabotulinumtoxinA (Botox) is FDA-approved specifically for prophylaxis of headache in adults with chronic migraine (15+ headache days per month, each lasting 4+ hours) 3, 4
• Botox treatment requires specialist administration with injections following a specific protocol 1
• Patients should receive at least 2-3 treatment cycles of Botox before being classified as non-responders 3
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are proven beneficial for patients in whom at least two other preventive medications have failed 1
• Regulatory restrictions often limit the use of Botox and CGRP antibodies to patients in whom two or three other preventive medications have failed 1

Acute Treatment Options

• First-line acute treatments include NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
• Paracetamol (acetaminophen) has less efficacy and should only be used in those intolerant to NSAIDs 1
• Second-line acute treatments include triptans, which are most effective when taken early in an attack while headache is still mild 1
• Sumatriptan requires careful consideration of contraindications, including coronary artery disease, uncontrolled hypertension, and history of stroke 5
• Medication overuse headache is a significant risk with frequent use of acute medications, requiring education and monitoring 1

Managing Medication Overuse Headache (MOH)

• MOH frequently causes symptoms that suggest chronic migraine and must be ruled out before establishing preventive treatment 1
• Management involves explanation and withdrawal of overused medication; abrupt withdrawal is preferred except for opioids 1
• Patients should be educated about the risk of MOH with frequent use of acute medications 1

Addressing Comorbidities

• Chronic migraine is commonly associated with anxiety, depression, sleep disturbances, and chronic pain conditions 1
• Obesity is an important risk factor for transformation from episodic to chronic migraine 1
• For patients with depression or sleep disturbances, amitriptyline may be beneficial despite limited evidence specifically for chronic migraine 1
• Comorbidity management is essential as their alleviation can improve treatment outcomes for migraine 1

Treatment Algorithm

1. Initial Assessment: Confirm chronic migraine diagnosis (15+ headache days/month for >3 months)
2. Rule out MOH: Address medication overuse if present
3. First-line Prevention: Start topiramate with gradual titration to 100 mg/day
4. Evaluate Response: Allow 2-3 months before assessing efficacy
5. Second-line Option: If topiramate fails or is not tolerated, refer to specialist for consideration of onabotulinumtoxinA (Botox)
6. Third-line Option: Consider CGRP monoclonal antibodies if previous treatments fail
7. Acute Treatment Plan: Provide appropriate acute medications (NSAIDs or triptans) with clear limits on frequency to prevent MOH
8. Address Comorbidities: Identify and treat associated conditions that may impact migraine management

Important Considerations and Pitfalls

• Beta blockers, candesartan, and amitriptyline lack robust data from randomized controlled trials for chronic migraine specifically, though they are commonly used in clinical practice 1
• Patients with chronic migraine should be referred to specialist care due to the challenging nature of management 1
• Long-term follow-up should maintain stability of adequate outcomes and react appropriately to any changes 1
• Avoid regular routine contact unless necessary, emphasizing patient education and self-efficacy regarding when to return for care 1