Chronic Migraine

Brief Overview: According to UpToDate, “Migraine is a neurologic disorder, the hallmark of which is a severe headache frequently associated with nausea and/or light and sound sensitivity. Migraine may be categorized as episodic or chronic types based on the frequency of headaches. Individuals with chronic migraine have headache for at least 15 days per month, and some have constant or daily headaches.”

Prevalence: According to UpToDate, “Chronic migraine affects approximately 2 percent of the world population.”

Etiology:

  • The etiology appears to be multifactorial, involving:
    • Genetic predisposition (familial tendency)
    • CNS hyperexcitability → cortical spreading depression
    • Trigeminovascular activation → neuropeptide release (CGRP, substance P)
    • Central sensitization from repeated attacks
  • Migraines can transform from episodic to chronic.

Risk Factors:

  • Female
  • Genetics
  • Obesity
  • Head injuries, concussions
  • Fibromyalgia and other pain disorders
  • Depression, anxiety
  • Sleep disorders
  • Stressful life events
  • Caffeine

Commonly Associated Conditions:

  • Depression, anxiety
  • Obesity
  • Sleep disorders
  • Asthma
  • Medication overuse headache
  • Chronic fatigue syndrome
  • Fibromyalgia

Common Medications:

Per UpToDate,

Common Labs, Imaging, and Tests:

  • Diagnosis typically made based on history and physical
  • MRI, CT may be indicated

Common Symptoms:

  • Chronic migraine: headaches ≥15 days/month, ≥8 migraine days/month, for more than 3 months
  • Unilateral
  • Throbbing, pulsatile
  • Attack severity increases over the course of one to several hours
  • Nausea, vomiting
  • Photophobia, phonophobia
  • Untreated headaches can last from 4 hours to several days
  • Aura in ~25% of patients – visual, sensory, language, motor

Common Treatments:

  • Occipital nerve block
  • Behavioral therapy
  • Physical therapy
  • Neuromodulation

Physical Findings:

  • Typically, normal neurologic exam between attacks
  • May see allodynia (pain from light touch) during attacks
  • Cervical muscle tenderness or tightness common
  • In severe chronic migraine: photophobia, phonophobia even baseline

Potential Complications and Contraindications:

  • Status migrainosus
  • Stroke (rare)
  • Aura-related seizures
  • Heart attack (rare)
  • Persistent aura without infarction

General Health and Lifestyle Guidance:

  • Maintain regular sleep, meals, hydration, exercise. Ask your healthcare provider for diet and exercise recommendations.
  • Limit caffeine and avoid alcohol if triggers
  • Stress management (mindfulness, relaxation, CBT)
  • Keep a headache diary (frequency, triggers, medication use) to share with your healthcare provider
  • Work with your healthcare provider to manage weight (obesity can worsen migraine)

Suggested Questions to Ask Patients:

  • How many days per month do you have headaches?
  • How many of those days feel like migraine?
  • What symptoms accompany the headaches (nausea, light/sound sensitivity, aura)?
  • What makes your headaches better/worse?
  • What medications are you using and how often?
  • Do headaches interfere with your sleep, work, or daily activities?
  • Do you have any history of depression, anxiety, or sleep apnea?
  • Do you have a family history of migraine or stroke?

Suggested Talking Points:

  • Chronic migraine is defined by frequent headache days, not just “bad headaches.”
  • It’s common and treatable; the goal is typically to reduce attack frequency and severity.
  • Both preventive and acute medications are available; overusing acute meds can worsen headaches.
  • Lifestyle measures (sleep, stress, exercise, hydration) are key parts of management.
  • Keeping a diary helps identify triggers and measure progress.
  • Ask your healthcare provider for warning signs/advice for when you should seek urgent/emergency treatment

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.