Chronic Migraine

Condition: 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,

First-line prophylactic medications include: propranolol, amitriptyline, topiramate, CGRP antagonists (eg, erenumab, fremanezumab, galcanezumab, eptinezumab, or atogepant), and onabotulinumtoxinA
Alternative options for patients with chronic migraine who have failed treatment with at least two first-line agents include occipital nerve blocks, candesartan, venlafaxine, valproic acidand its derivatives, verapamil, other beta blockers, gabapentin, magnesium, riboflavin, or other tricyclic antidepressants.
Third-line agents for those who fail treatment with first- and second-line agents include feverfew, tizanidine, memantine, pregabalin, cyproheptadine, and zonisamide

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:

⚠️ Medical Disclaimer

This resource is provided for educational and informational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. The information presented is general in nature and may not apply to every individual or health situation.

Individuals should consult their physician or other qualified healthcare professional for personalized medical advice, diagnosis, or treatment recommendations related to their specific health conditions and should not begin any new exercise program or change their diet or medications without consulting their healthcare professional.

Call 911 if you are experiencing a medical emergency.

Chronic Migraine - Neuro

Condition: Chronic Migraine