What are the treatment options for chronic migraines?

Chronic Migraine Treatment

For chronic migraine (≥15 headache days per month), initiate topiramate as first-line preventive therapy, titrating gradually to 100 mg/day, with onabotulinumtoxinA or CGRP monoclonal antibodies reserved for patients who fail topiramate or two other preventive medications. 1

Diagnostic Confirmation and Baseline Assessment

• Confirm the diagnosis meets chronic migraine criteria: ≥15 headache days per month for at least 3 months, with migraine features on at least 8 days per month 1, 2
• Rule out medication overuse headache (MOH), which frequently mimics chronic migraine and requires withdrawal of overused medications before initiating preventive therapy 1
• Implement a headache diary to track frequency, severity, triggers, and medication use—this is essential for monitoring treatment response 1, 2
• Use validated assessment tools: Headache Impact Test-6 (HIT-6) and Migraine-Specific Quality-of-Life Questionnaire (MSQ) to quantify disease burden 1, 2

Acute Treatment During Chronic Migraine

• Limit acute medication use to no more than twice weekly to prevent medication overuse headache 3
• First-line: NSAIDs (aspirin, ibuprofen, or diclofenac potassium) plus prokinetic antiemetics (domperidone or metoclopramide) when nausea/vomiting present 1, 2
• Second-line: Triptans when NSAIDs provide inadequate relief, taken early when headache is still mild 1, 4
• Avoid ergot alkaloids, opioids, and barbiturates due to questionable efficacy and high risk of dependency and medication overuse headache 3

Preventive Medication Algorithm

First-Line: Topiramate

• Topiramate is the drug of first choice for chronic migraine due to proven efficacy and substantially lower cost compared to biologics 1
• Gradually titrate to 100 mg/day to minimize adverse effects 2
• Particularly beneficial in patients with obesity due to associated weight loss 1, 2
• Common adverse effects include cognitive slowing, paresthesias, and kidney stones 1

Second-Line: OnabotulinumtoxinA

• FDA-approved specifically for chronic migraine (not episodic migraine) 1, 5
• Indicated when topiramate and at least one other preventive medication have failed 1
• Administered as 155 units injected into specific head and neck muscle sites 1
• Serious risks include spread of toxin effects causing botulism-like symptoms (muscle weakness, swallowing/breathing problems), though not confirmed at recommended doses for chronic migraine 5
• Contraindicated in patients with neuromuscular disorders (ALS, myasthenia gravis, Lambert-Eaton syndrome) 5

Third-Line: CGRP Monoclonal Antibodies

• Three agents proven effective: erenumab, fremanezumab, and galcanezumab 1
• Reserved for patients who have failed at least two or three other preventive medications due to regulatory restrictions and high cost 1
• Demonstrated benefit even in treatment-refractory chronic migraine 1

Alternative Preventive Options (Less Evidence in Chronic Migraine)

• Beta-blockers (propranolol, metoprolol), candesartan, and amitriptyline lack robust randomized controlled trial data specifically for chronic migraine, though commonly used in clinical practice 1
• Amitriptyline is preferred when depression or sleep disturbances are comorbid 1
• Beta-blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, bisoprolol) are beneficial when hypertension or tachycardia coexist 1, 2

Comorbidity Management

• Identify and treat comorbid conditions—depression, anxiety, sleep disorders, obesity, and chronic pain—as their management directly improves migraine outcomes 1, 2
• Obesity is a critical modifiable risk factor for transformation from episodic to chronic migraine and must be addressed 1
• Adjust medication selection based on comorbidity profile: topiramate for obesity, amitriptyline for depression/insomnia, beta-blockers for hypertension 1, 2

Non-Pharmacological Interventions

• Offer cognitive-behavioral therapy (CBT), biofeedback, and relaxation training to all patients as these have proven efficacy comparable to pharmacological treatments 1, 2
• Exercise 40 minutes three times weekly is as effective as topiramate or relaxation therapy for migraine prevention 1
• Implement stress management, regular sleep patterns, and adequate hydration 2
• Identify and modify true trigger factors when self-evident, but avoid unnecessary avoidance behaviors that damage quality of life 1

Patient Education and Expectations

• Educate patients that chronic migraine is a neurological disorder with biological basis requiring multimodal, multidisciplinary treatment—not a psychological condition 1
• Set realistic expectations: chronic migraine management is often a long process requiring patience and multiple treatment adjustments 1
• The goal is returning control from the disease to the patient, reducing attack frequency, duration, and intensity to minimize disability 1
• Emphasize that complete headache elimination is rarely achievable; focus on functional improvement and quality of life 1

Specialist Referral Indications

• Refer to headache specialist for: confirmed chronic migraine diagnosis, failure of multiple preventive medications, consideration of onabotulinumtoxinA or CGRP antibodies, or diagnostic uncertainty 1, 2
• Specialist care is usually necessary for optimal chronic migraine management 1
• Coordinate timely return to primary care once treatment is established for long-term management 1

Critical Pitfalls to Avoid

• Do not initiate preventive therapy without first ruling out and treating medication overuse headache, as MOH will prevent response to preventive medications 1
• Do not allow unlimited acute medication use—strict limitation to twice weekly prevents progression and medication overuse headache 3
• Do not prescribe triptans in patients with cardiovascular disease, uncontrolled hypertension, or history of stroke/TIA 4
• Do not use beta-blockers in patients with depression, as this may worsen the comorbidity 1
• Monitor for serotonin syndrome when combining triptans with SSRIs, SNRIs, or MAO inhibitors 4