What is the recommended treatment approach for a patient with chronic migraine?

Chronic Migraine SOAP Note

Subjective

Chief Complaint & History of Present Illness:

• Document headache frequency (must be ≥15 headache days per month for ≥3 months, with migraine features on ≥8 days) 1, 2
• Record current acute medication use frequency—specifically ask about use more than twice weekly, which indicates high risk for medication overuse headache (MOH) 1, 2
• Identify specific triggers: alcohol, caffeine, tyramine-containing foods, nitrates, stress, fatigue, perfumes, fumes, glare, and flickering lights 3
• Quantify disability using validated tools: HIT-6 (Headache Impact Test-6) and MIDAS (Migraine Disability Assessment) scores 2
• Screen for comorbidities: depression, anxiety, sleep disturbances, obesity, and chronic pain conditions 1, 2

Medication History:

• List all current acute medications (NSAIDs, triptans, opioids, ergotamines, butalbital-containing compounds) with exact frequency of use 3
• Document previous preventive medication trials, doses achieved, duration of adequate trial (2-3 months minimum), and reasons for discontinuation 3, 1

Objective

Physical Examination:

• Perform focused neurological examination to rule out secondary causes and identify any contraindications to specific treatments 2
• Document blood pressure (uncontrolled hypertension contraindicates triptans) 3
• Assess for signs of depression, anxiety, or other psychiatric comorbidities 1, 2

Diagnostic Confirmation:

• Confirm chronic migraine diagnosis: ≥15 headache days per month for ≥3 months with migraine features on ≥8 days 2
• Rule out medication overuse headache first—MOH is defined as regular overuse of acute medications (≥10 days/month for triptans, ergots, opioids, combination analgesics; ≥15 days/month for simple analgesics) for >3 months 1, 2

Assessment

Primary Diagnosis: Chronic Migraine (ICD-10: G43.709)

Secondary Diagnoses (if applicable):

• Medication Overuse Headache (if acute medication use exceeds twice weekly) 1, 2
• Comorbid conditions: depression, anxiety, sleep disorder, obesity 1, 2

Severity Assessment:

• Quantify using HIT-6 and MIDAS scores 2
• Document number of disability days per month 3, 2

Plan

Step 1: Address Medication Overuse Headache (if present)

If MOH is identified, this MUST be addressed before initiating preventive therapy, as MOH prevents response to preventive medications. 2

• Educate patient that continued overuse will perpetuate chronic headache pattern 1, 2
• Implement abrupt withdrawal of overused medication (except opioids, which require tapering) 1
• Warn patient about temporary worsening during withdrawal period 1
• Limit all acute medication use to maximum twice weekly going forward 1, 2

Step 2: Initiate First-Line Preventive Therapy

Start topiramate as first-line preventive therapy due to proven efficacy and lower cost compared to biologics. 1, 2

• Begin topiramate 25 mg daily at bedtime 1, 4
• Titrate by 25 mg weekly to target dose of 100 mg/day 1, 4
• Allow dosing flexibility from 50-200 mg/day based on response and tolerability 4
• Counsel patient about common side effects: paresthesias (53%), nausea, dizziness, fatigue, anorexia, cognitive effects ("disturbance in attention") 4, 5
• Emphasize that most adverse events are mild-to-moderate and transient 5
• Topiramate may be particularly beneficial if patient has comorbid obesity due to associated weight loss 1
• Evaluate response after 2-3 months before assessing efficacy, though benefit may appear as early as first month 3, 5

Step 3: Establish Acute Treatment Plan

First-line acute treatment: NSAIDs with strict frequency limits 3, 1, 2

• Prescribe aspirin 1000 mg, ibuprofen 400-600 mg, or diclofenac potassium 50-100 mg for acute attacks 3, 1
• Add prokinetic antiemetic (metoclopramide 10 mg or domperidone 10 mg) when nausea/vomiting is present 2
• Strictly limit use to maximum twice weekly to prevent MOH 1, 2

Second-line acute treatment: Triptans (if NSAIDs inadequate) 3, 1

• Prescribe oral sumatriptan 50-100 mg, rizatriptan 10 mg, or zolmitriptan 2.5-5 mg 3
• Instruct patient to take early in attack while headache is still mild for maximum efficacy 1
• Contraindications: uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine 3
• Strictly limit use to maximum twice weekly 1, 2

Avoid: ergotamines, opioids, and butalbital-containing compounds due to high risk of dependency and MOH 2

Step 4: Second-Line Preventive Therapy (if topiramate fails or not tolerated)

OnabotulinumtoxinA (Botox) is indicated after failure of topiramate and at least one other preventive medication. 1, 2

• FDA-approved specifically for chronic migraine prophylaxis (≥15 headache days/month, each lasting ≥4 hours) 1, 6
• Requires specialist administration with specific injection protocol (155-195 units across 31-39 sites in head/neck) 1
• Administer every 12 weeks 1
• Requires at least 2-3 treatment cycles before classifying as non-responder 1
• Counsel about serious risks: dysphagia, dysphonia, dysarthria, respiratory compromise, and spread of toxin effects (though not confirmed at recommended doses for chronic migraine) 6
• Refer to headache specialist for Botox administration 2

Step 5: Third-Line Preventive Therapy (if Botox fails)

CGRP monoclonal antibodies are reserved for patients who have failed at least two other preventive medications. 1, 2

• Options: erenumab 70-140 mg monthly, fremanezumab 225 mg monthly or 675 mg quarterly, galcanezumab 240 mg loading then 120 mg monthly 1
• These are subcutaneous injections that patients can self-administer 1
• Reserved for refractory cases due to high cost and regulatory restrictions 2

Step 6: Address Comorbidities

Comorbidity management is essential as their treatment directly improves migraine outcomes. 1, 2

• Depression/anxiety: Consider amitriptyline 30-150 mg at bedtime (though evidence specifically for chronic migraine is limited) 3, 1
• Obesity: Implement weight loss program—obesity is a critical modifiable risk factor for episodic-to-chronic migraine transformation 1, 2
• Sleep disturbances: Optimize sleep hygiene; consider amitriptyline if insomnia present 1
• Chronic pain conditions: Coordinate multidisciplinary pain management 1, 2

Step 7: Non-Pharmacological Interventions

Offer cognitive-behavioral therapy (CBT), biofeedback, and relaxation training—these have efficacy comparable to pharmacological treatments. 2

• Prescribe regular aerobic exercise: 40 minutes three times weekly (as effective as topiramate for prevention) 2
• Refer to behavioral medicine or headache psychologist for CBT and biofeedback 2

Step 8: Patient Education

• Provide headache diary to track frequency, severity, duration, triggers, medication use, and disability 3, 2
• Educate that chronic migraine is a neurological disorder with biological basis, not a psychological condition 2
• Explain that treatment goal is reducing attack frequency, duration, and intensity to minimize disability and return control to patient 2
• Emphasize that preventive medication requires 2-3 months for full effect 3, 5
• Reinforce strict limitation of acute medications to twice weekly maximum 1, 2

Step 9: Specialist Referral

Refer to headache specialist for: 2

• Confirmed chronic migraine diagnosis requiring specialist-level management
• Failure of multiple preventive medications
• Consideration of onabotulinumtoxinA or CGRP antibodies
• Diagnostic uncertainty
• Chronic migraine usually requires specialist care for optimal management 1, 2

Step 10: Follow-Up Plan

• Schedule follow-up in 4 weeks to assess topiramate tolerability and titration progress 1, 5
• Schedule comprehensive efficacy assessment at 2-3 months after reaching target dose 3, 5
• Reassess HIT-6 and MIDAS scores at 3-month intervals 2
• Review headache diary at each visit 3, 2
• Once stable, avoid routine contact unless necessary—emphasize patient self-efficacy regarding when to return 1

Critical Pitfalls to Avoid:

• Never initiate preventive therapy without first ruling out and treating MOH—MOH will prevent response to preventive medications 2
• Never allow unlimited acute medication use—strict twice-weekly limitation prevents progression and MOH 1, 2
• Do not use acetaminophen alone—it is ineffective for migraine 3
• Do not prescribe triptans to patients with uncontrolled hypertension or cardiovascular disease 3
• Do not classify patient as non-responder to Botox until after 2-3 treatment cycles 1