Chronic Migraine

Chronic Migraine

Overview

Chronic migraine is a condition where you have frequent or long-lasting episodes of headaches and migraines. With chronic migraine, your symptoms can shift daily (or even hour to hour). That can make it hard to tell where one migraine or headache ends and another begins.

Symptoms

Chronic migraine symptoms are the same as those of episodic migraines. Chronic migraines simply last longer or happen more often. Chronic migraine also involves headaches.

To receive this diagnosis, you must have:

At least 15 days in a month where you experience a headache or migraine. This must happen for at least three months.

At least eight days per month where your headaches include migraine symptoms or features. This must happen for at least three months.

Migraines symptoms

As mentioned, migraines aren’t the same as headaches, and they can take different forms. The symptoms you experience from migraine to migraine can also vary. Migraines happen in up to four stages (but not every migraine involves all four):

Prodrome: This is a pre-migraine stage. You can often feel subtle differences that hint that a migraine is forthcoming.

Aura: These are symptoms that happen as a migraine disrupts different areas of your brain.

Headache: This is the pain stage of a migraine.

Postdrome: This is when you feel the aftereffects of a migraine. A common way to describe it is like a “migraine hangover.”

With chronic migraine, your symptoms must meet the following criteria:

Migraine without aura (must last between four hours and 72 hours)

A headache phase that meets at least two of the following criteria:

Pain on one side (left or right) of your head.

Pain that has a pulsing or pounding feel.

Pain that’s moderate or severe.

Pain that worsens with even basic levels of activity (such as walking or using stairs) or makes you avoid activity.

A headache phase that involves at least one of the following:

Nausea.

Vomiting.

Both light sensitivity (photophobia) and sound sensitivity (phonophobia).

Migraine with aura

One or more of the following types of aura symptoms:

Visual (flashing lights, haze, zig-zag-like areas around the center of your vision or other vision changes).

Touch (tingling or numbness).

Speech/language (difficulty speaking or understanding what others say).

Motor (hemiplegia, which is one-sided weakness or paralysis, affecting your body and/or face).

Brainstem (loss of coordination, balance issues, vertigo, tinnitus or digestive problems like diarrhea or constipation).

Retinal (one-sided blindness, either partial or total, or shimmering areas).

At least three of the following criteria:

At least one aura symptom spreads gradually over five minutes or longer.

Two or more aura symptoms in succession.

Each aura symptom lasts between five minutes and one hour.

At least one aura symptom is one-sided.

At least one aura symptom with positive symptoms (“good” means the symptoms add an effect; negative symptoms cause you to partly or completely lose the affected ability).

A headache phase that occurs at the same time or within 60 minutes after an aura.

Causes

Migraines can be genetic, meaning you’re more likely to have migraines if you have a close biological relative, especially a parent or grandparent, with this condition.

Researchers also suspect several processes could contribute to migraines, including:

Blood flow changes in your brain because of a widening or narrowing of blood vessels.

Temporary changes that make it harder for brain cells to conduct electrical signals.

Brain chemistry changes, including shifts in levels of neurotransmitters like serotonin.

Incorrect signaling from nerve clusters around your eyes or elsewhere on your head.

Malfunctions in pain/signal processing centers in different areas of your brain.

Changes in how your body processes and feels pain because of the effects of chronic pain.

Risk factors

Several factors increase your risk of developing chronic migraine or contribute to making it worse. These include having:

Obesity.

Head injuries like concussions.

Other chronic conditions, especially pain-related conditions like fibromyalgia.

Mental health conditions like depression or anxiety.

Sleep disorders, especially sleep apnea.

Migraine transformation

Episodic migraines can sometimes “transform” into chronic migraine. That often happens because of processes that experts still don’t fully understand. There’s evidence that overuse of certain migraine treatments is a possible contributor to this transformation. The term “overuse” here doesn’t automatically refer to a substance use disorder, and it can happen even with medications that aren’t habit-forming.

Because of the risk of transformation, experts strongly recommend against frequent use of certain medications if you have episodic migraine. Medication overuse can also act as a trigger in some cases.

Triggers

Foods, substances, smells, sounds or other environmental factors or circumstances can trigger the start of a migraine, typically within hours or days.

The most common triggers include:

Stress or anxiety.

Hormone changes related to menstruation.

Hunger or dehydration.

Barometric pressure changes (such as those that happen with weather changes).

Sleeping too much or not enough.

Certain scents, fragrances or odors.

Certain foods or food additives (aged cheeses, red wines, chocolate and aged or preserved meats are some of the most common examples).

Light (certain types of lighting, or an intense reflection or glare off a reflective surface — even for a fraction of a second — pointed directly at one or both eyes can trigger a migraine).

Caffeine (especially having too much or less than your usual amount).

Certain sounds, especially low-frequency sounds like jackhammering or high-frequency sounds like power tools.

Frequent headache medication use (these are known as medication overuse headaches or “rebound” headaches).

Complications

Complications of migraines are possible but uncommon. They include:

Status migrainosus (a severe migraine that lasts at least three days).

Strokes.

Aura-related seizures.

Heart attacks (very rare).

Diagnosis

A healthcare provider can diagnose migraines using a combination of approaches. A neurological exam is usually one of the first steps. Your provider will also ask questions about your health history, daily life, routine and activities. Questions usually relate to:

What the headache feels like, especially your description of the pain, the pain’s location in your head and the pain’s severity.

If you’ve ever had a migraine before and, if yes, how often they happen.

If your headaches involve other symptoms, such as light or sound sensitivity.

If you drink beverages that contain caffeine and, if yes, how much you typically drink.

If you have any possible migraine triggers (like foods, beverages, fragrances, smells, sounds, etc.).

How much you typically sleep and your recent sleep habits.

Your typical stress and anxiety levels and if there’s anything causing stress or anxiety for you now or recently.

Your provider may recommend certain tests, especially diagnostic imaging scans, such as a computed tomography (CT) scan, to rule out life-threatening conditions like stroke. This is most likely when you have severe neurological symptoms, especially hemiplegia, as this is a key sign of a stroke. In non-emergency situations, you may have a magnetic resonance imaging (MRI) scan instead of or along with a CT scan.

Other tests are also possible, depending on your symptoms. Your healthcare provider is the best person to tell you more about the tests they recommend and why they think these tests are necessary

Treatment

Chronic migraine treatments are similar to migraine treatments in general. Medications are the main form of treatment, and there are two main treatment approaches:

Preventive: This uses medications to prevent migraines or make them less severe or less frequent.

Rescue: These medications “rescue” you, meaning they shorten migraines and make them less severe.

There are medical procedures that may be an option for chronic migraine. Mental healthcare options can also be a part of treatment.

Preventive medications

Preventive medications are useful for chronic migraine because they make migraines less severe or happen less often. Preventive medications can include:

Angiotensin II receptor blockers (ARBs), such as candesartan.

Antiseizure medications (such as valproic acid or topiramate.

Antidepressants, such as amitriptyline, nortriptyline or venlafaxine.

Beta-blockers, such as atenolol, metoprolol or propranolol.

Botulinum toxin (Botox®) injections.

Calcium channel blockers (CCBs), such as verapamil or flunarizine.

Monoclonal antibody-based injection treatments, such as erenumab (Aimovig®), fremanezumab (Ajovy®) or galcanezumab (Emgality®).

Rescue medications

These medications shorten a migraine and/or make it less severe. Experts often recommend using these carefully because overuse can lead to or worsen chronic migraine.

Over-the-counter (OTC) and nonsteroidal anti-inflammatory drugs (NSAIDs)

OTC and NSAID medications that can treat migraines include:

Acetaminophen (sometimes known under the generic name paracetamol, and often better known under the brand names Tylenol® and Panadol®).*

Aspirin.

Ibuprofen (also known under the brand names Advil® and Motrin®).

Naproxen (also known under the brand names Aleve® or Naprosyn®).

Some over-the-counter migraine medications combine NSAIDs with caffeine. It’s a good idea to talk to your provider about whether or not to avoid caffeine-containing products, and to read labels to make sure you’re not taking these products unintentionally.

Triptan medications

These are typically the first-line prescriptions for migraines. These drugs (including the brand names most often used) are:

Almotriptan (the brand name drug, Axert, is no longer available in the U.S.)

Eletriptan (Relpax®).

Frovatriptan (Frova®).

Naratriptan (Amerge®).

Rizatriptan (Maxalt®).

Sumatriptan (Imitrex® or Onzetra®).

Zolmitriptan (Zomig®).

Your healthcare provider may recommend against using these to treat chronic migraine. Using these too often can cause medication overuse headaches or contribute to transforming episodic migraines into chronic migraine.

Ergotamine

This medication causes blood vessels in your brain to narrow and affects pain signal processing. The brand name form of ergotamine is Ergomar®. Brand name combinations of ergotamine and caffeine include Cafergot® and Migergot®.

Controlled and combination medications

These drugs combine an NSAID and a controlled medication, such as a barbiturate or an opioid painkiller. These can make chronic migraine worse, so they aren’t common in treating this condition.

Medical procedures

There are a few medical procedures that may help with chronic migraine, including:

Nerve stimulation: The most common nerves for this are the vagus nerve, the occipital nerve (at the back of your head) and the supraorbital nerves (on your forehead).

Transcranial magnetic stimulation (TMS): This treatment uses a magnetic field to influence your brain’s electrical activity.

Alternative treatment methods: Other therapies, such as acupuncture (or acupuncture-like methods), may help chronic migraine. While these aren’t as common, they may still help. There are also physicians and other trained and licensed healthcare professionals who offer these treatments.

Mental healthcare

Psychotherapy (the formal term for mental health therapy) may help people with stress and anxiety, which both contribute to migraines. There are many forms of psychotherapy, so you have options to choose from when looking for a method that works for you.

Type of Doctor Department : A neurologist