What are the management options for headache and chronic migraine?

Management of Headache and Chronic Migraine

For chronic migraine (≥15 headache days/month for ≥3 months with ≥8 migraine days/month), initiate prophylactic therapy with topiramate as first-line medication, as it is the only oral agent with proven efficacy in randomized placebo-controlled trials specifically for chronic migraine, or consider onabotulinumtoxinA (Botox), which is FDA-approved for chronic migraine prophylaxis. 1

Diagnostic Approach

Rule out secondary causes first through careful history and physical examination looking specifically for "red flags" including sudden onset ("thunderclap"), new onset after age 50, progressive worsening, fever/systemic symptoms, focal neurological deficits, papilledema, or headache triggered by Valsalva maneuvers. 1

Establish the diagnosis of chronic migraine by asking: "Do you feel like you have a headache of some type on 15 or more days per month?" This direct question is critical because patients typically underreport milder headaches and only mention severe days. 1, 2

Require patients to maintain a headache diary to accurately document frequency, severity, triggers, medication use, and response to treatment—this is essential for both diagnosis and monitoring. 1, 2

Prophylactic Pharmacological Management

First-Line Options

Topiramate is the evidence-based first choice, with Level A efficacy (≥2 Class I trials) specifically in chronic migraine populations. Start low and titrate slowly to minimize cognitive side effects, paresthesias, and weight loss. 1, 2

OnabotulinumtoxinA (Botox) 155 units is the only FDA-approved therapy specifically for chronic migraine prophylaxis, based on the large Phase III PREEMPT trials showing reduction in headache days, episodes, cumulative hours, and improved quality of life. This requires administration by a neurologist or headache specialist using the PREEMPT protocol. 1

Alternative Prophylactic Agents

For patients who cannot tolerate topiramate or Botox, consider these options with varying evidence levels:

• Valproate: Level A efficacy for episodic migraine, small trials in chronic daily headache; monitor for weight gain, tremor, liver toxicity, and thrombocytopenia 1
• Amitriptyline: Second-choice drug with small open-label trial data in transformed migraine; useful when comorbid depression or insomnia present; monitor for anticholinergic effects and cardiac dysrhythmias 1
• Gabapentin: Level U evidence (inadequate data); one double-blind trial in chronic daily headache 1
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Emerging alternatives with favorable side effect profiles 2

Critical Medication Selection Strategy

Match prophylactic medication to comorbidities to treat both conditions simultaneously:

• Topiramate for patients with obesity (causes weight loss) 2
• Amitriptyline for comorbid depression or insomnia 1
• Avoid beta-blockers in patients with asthma, diabetes, bradycardia, or depression 1

When monotherapy fails, consider polytherapy combining agents with different mechanisms. 1

Acute/As-Needed Medication Management

Strictly limit acute medication use to prevent medication overuse headache, which affects up to 73% of chronic migraine patients:

• Simple analgesics (acetaminophen, NSAIDs): <15 days/month 2
• Triptans: <10 days/month 2
• Never use opioids or butalbital-containing compounds due to high risk of medication overuse headache and dependence 3

If medication overuse is present, withdraw the overused medication abruptly (except opioids, which require tapering) and educate patients about the risk. 2, 3

Non-Pharmacological Management

Offer behavioral interventions to all patients as these provide meaningful benefit and should not be considered optional:

• Cognitive-behavioral therapy (CBT) and biofeedback have demonstrated efficacy for symptom relief 1, 2
• Exercise 40 minutes three times weekly showed equivalence to topiramate or relaxation therapy in randomized trials—this is not adjunctive but a primary intervention 1, 2
• Relaxation training, meditative therapy (abdominal breathing), progressive muscle relaxation, and visualization/guided imagery 1, 2

Modifiable Risk Factors and Triggers

Systematically identify and address these factors as they directly impact treatment success:

• Obesity (consider topiramate for dual benefit) 1, 2
• Caffeine overuse 1
• Obstructive sleep apnea (requires sleep study and treatment) 1
• Psychiatric comorbidities (anxiety, depression—screen and treat) 1, 2
• Stress (behavioral interventions to modify stress response) 1

Primary Care Physician Role and Specialist Collaboration

PCPs serve as the primary point of care for 80.1% of chronic migraine patients and should:

1. Make the initial diagnosis and rule out secondary causes 1
2. Refer to headache specialist for diagnostic confirmation and treatment planning 1, 2
3. Initiate prophylactic therapy (topiramate or other oral agents) while awaiting specialist appointment 1
4. Monitor treatment response between specialist visits using disability assessment tools (HIT-6, MSQ) 1, 2
5. Enforce medication limits and headache diary compliance 1
6. Manage comorbid conditions appropriately 1

Refer back to specialist if chronic migraine does not improve with treatment or new symptoms arise. 1

Patient Education and Expectations

Educate patients that chronic migraine is a neurological disorder with biological basis involving functional and structural nervous system changes, not a psychological problem. 1

Set realistic expectations explicitly: chronic migraine requires multimodal, multidisciplinary long-term management with periods of relapse and remission—the road to recovery is long but achievable in the majority. 1, 2

Patient empowerment through education, non-pharmacologic treatments, and realistic expectations is key to improving quality of life in this underrecognized and undertreated population. 1

Common Pitfalls to Avoid

• Failing to diagnose chronic migraine because patients only report severe headache days—only 20% of patients meeting criteria are correctly diagnosed 1
• Using episodic migraine prophylaxis without evidence in chronic migraine—only topiramate and onabotulinumtoxinA have specific chronic migraine trial data 1
• Allowing medication overuse to continue without intervention—this perpetuates the chronic pattern 2, 3
• Prescribing opioids or butalbital compounds—these worsen outcomes and create dependence 3
• Neglecting non-pharmacological interventions—these have equivalent efficacy to some medications 1, 2