What is the recommended treatment approach for an adult patient with chronic migraines and no significant medical history?

Chronic Migraine Treatment

For an adult patient with chronic migraine (≥15 headache days per month for at least 3 months), start with topiramate 100 mg/day as first-line preventive therapy after ruling out medication overuse headache, and limit acute medications to no more than twice weekly to prevent progression. 1, 2

Initial Assessment and Diagnosis Confirmation

• Confirm chronic migraine diagnosis: ≥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) first—this is critical because MOH mimics chronic migraine and will prevent response to any preventive medication 1, 3, 2
• MOH occurs when acute medications are used ≥10 days per month 3
• If MOH is present, withdraw overused medications abruptly (except opioids) before initiating preventive therapy 1, 3
• Implement a headache diary tracking frequency, severity, triggers, medication use, and disability 1, 3, 2
• Use validated assessment tools: Headache Impact Test-6 (HIT-6) and Migraine-Specific Quality-of-Life Questionnaire (MSQ) to quantify disease burden 3, 2

First-Line Preventive Therapy

Topiramate is the recommended first-line preventive medication for chronic migraine 1, 2:

• Start low and titrate gradually to 100 mg/day 1, 3
• Particularly beneficial for patients with obesity due to associated weight loss 1, 3
• Allow 2-3 months for adequate therapeutic trial before assessing efficacy 1
• Common side effects include paresthesias, cognitive difficulties, and weight loss 1

Alternative first-line options if topiramate is contraindicated or not tolerated:

• Amitriptyline 30-150 mg/day, especially when comorbid depression or sleep disorders exist 4, 3
• Note: Beta-blockers (propranolol, timolol), candesartan, and amitriptyline lack robust randomized controlled trial data specifically for chronic migraine, though they have proven efficacy for episodic migraine 4, 1

Second-Line Preventive Therapy

OnabotulinumtoxinA (Botox) is indicated when topiramate and at least one other preventive medication have failed 1, 2:

• FDA-approved specifically for chronic migraine prophylaxis (≥15 headache days per month, each lasting ≥4 hours) 1, 5
• Requires specialist administration following a specific injection protocol 1
• Patients need at least 2-3 treatment cycles before being classified as non-responders 1
• Well tolerated with lower discontinuation rates than oral medications 6
• Serious risks include spread of toxin effects causing botulism-like symptoms (weakness, swallowing/breathing problems), though not confirmed at recommended doses for chronic migraine 5

Third-Line Preventive Therapy

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are reserved for patients who have failed at least 2-3 other preventive medications 1, 3, 2:

• Limited by high cost and insurance restrictions 1, 6
• Proven beneficial specifically in treatment-refractory chronic migraine 1
• May work faster than oral medications and do not require titration 7

Acute Treatment Strategy

Strictly limit acute medication use to no more than twice weekly to prevent medication overuse headache 4, 1, 3, 2:

First-line acute treatment:

• NSAIDs (aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 275-550 mg) 4, 3
• Add prokinetic antiemetic (metoclopramide 10 mg or domperidone) if nausea is present 3

Second-line acute treatment when NSAIDs fail:

• Triptans: oral naratriptan, rizatriptan, zolmitriptan, or sumatriptan 4, 3
• Subcutaneous sumatriptan provides fastest onset 3
• Contraindicated in uncontrolled hypertension, coronary artery disease, hemiplegic/basilar migraine 4, 8
• Risk of coronary vasospasm, arrhythmias, and serotonin syndrome when combined with SSRIs/SNRIs 8

Non-oral routes (nasal spray, subcutaneous, suppository) when attacks present early with nausea/vomiting 4, 3

Avoid ergot alkaloids, opioids, and barbiturates due to high risk of dependency and medication overuse headache 3

Comorbidity Management

Identify and aggressively treat comorbid conditions—their management directly improves migraine outcomes 1, 3, 2:

• Depression and anxiety 1, 3, 2
• Sleep disorders (emphasize regular sleep schedules) 3, 2
• Obesity is the single most critical modifiable risk factor for transformation from episodic to chronic migraine—weight loss is essential 1, 3, 2
• Chronic pain conditions 1, 3, 2

Non-Pharmacological Interventions

Offer cognitive-behavioral therapy (CBT), biofeedback, and relaxation training—these have proven efficacy comparable to pharmacological treatments 3, 2:

• Regular exercise (40 minutes three times weekly) is as effective as topiramate or relaxation therapy for prevention 3, 2
• Additional lifestyle modifications: regular sleep patterns, stress management, adequate hydration, regular meals, avoiding excessive caffeine and alcohol 3

Specialist Referral Indications

Refer to headache specialist for 1, 3, 2:

• Confirmed chronic migraine diagnosis (≥15 headache days/month) 1, 2
• Failure of multiple preventive medications 1, 2
• Consideration of onabotulinumtoxinA or CGRP antibodies 1, 2
• Diagnostic uncertainty 2

Critical Pitfalls to Avoid

• Never initiate preventive therapy without first ruling out and treating medication overuse headache—MOH will completely prevent response to preventive medications 1, 3, 2
• Never allow unlimited acute medication use—strict limitation to twice weekly is mandatory to prevent progression and medication overuse headache 4, 1, 3, 2
• Do not expect immediate results—preventive medications require 2-3 months for adequate therapeutic trial 4, 1
• Do not use acetaminophen alone—it lacks efficacy for migraine 4, 3

Patient Education

• Educate that chronic migraine is a neurological disorder with biological basis requiring multimodal treatment, not a psychological condition 3, 2
• Set realistic expectations: the goal is reducing attack frequency, duration, and intensity to minimize disability, not complete elimination of all headaches 3, 2
• Chronic migraine management is often a long process requiring patience and treatment adjustments 3