Chronic migraine - also called "transformed migraine" - is migraine headache more than 15 days/month.

30% with episodic migraine eventually develop a chronic pattern - 3% 'transform' to chronic migraine each year.

Effective migraine treatment lowers the risk of developing chronic migraine.

Chronic Migraine

Chronic migraine is migraine headache more than 15 days/month.

Also called “migraine transformation” because in most it begins with episodic migraine – the migraine pattern then gradually transforms to one of near daily headache.

Near constant headaches are often a mix of migraine and ‘tension-type’ headaches.

Approximately 1% of adults meet the criteria for chronic migraine.

90% of chronic migraine patients are women who first had episodic migraine without aura.

Up to 30% of those with migraine may eventually develop chronic migraine.

The migraine pattern ‘transforms’ to that of chronic migraine in about 3% of episodic migraine patients each year.

Those at highest risk of migraine transformation include:

  • Women, especially Caucasian women.
  • Those with at least one episodic migraine per week.
  • Those with longer duration of disease – migraine usually began in teens or 20’s – ‘transforms’ in 40’s.
  • Those who are overweight – obesity raises the risk of transformation to chronic migraine 5x.
  • Those with sleep apnea or who snore.
  • Those with a history of head injury.
  • Those using acute migraine medications more than 2 days/week.
  • Those who are ‘heavy’ users of caffeine.
  • Those with major life stress may have a 3x greater risk of migraine transformation.

Early, effective treatment of migraine disease may reduce the risk of transformation.

Effective migraine prevention may reduce the risk of transformation.

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Navigation

Scroll past "thoughts" and "primary vs. secondary" for a list of recent chronic migraine posts, followed by all chronic migraine posts.

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alert!I don't want to read - I just want relief from chronic migraine.

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Thoughts on Chronic Migraine

Migraine transformation

Migraine can be characterized as a chronic disorder with episodic attacks and the potential for progression to chronic migraine.

Unlike other neurological disease, migraine does not worsen over time as a matter of course. Migraine may be stable. It may diminish in frequency or severity. Or migraine can worsen, most often gradually, until the chronic pattern emerges.

Migraine progression to chronic migraine is relatively uncommon. Migraine is more likely to be stable, or to remit (especially over age 50.) Nonetheless, migraine progression is not uncommon and, because it is associated with severe impairment, deserves special attention.

Risk of migraine transformation

Those at highest risk of migraine transformation include:

  • Women, especially Caucasian women.
  • Those with at least one episodic migraine per week.
  • Those with longer duration of disease – migraine usually began in teens or 20’s – ‘transforms’ in 40’s.
  • Those who are overweight – obesity raises the risk of transformation to chronic migraine 5x.
  • Those with sleep apnea or who snore.
  • Those with a history of head injury.
  • Those using acute migraine medications more than 2 days/week.
  • Those who are ‘heavy’ users of caffeine.
  • Those with major life stress may have a 3x greater risk of migraine transformation.

Character of chronic migraine

The transformation to a chronic pattern usually takes place over years and is characterized by gradual change in the character of headache as well as its frequency. Of interest, the intensity of associated headaches may diminish. Excessive sensitivity to light (photophobia) and sound (phonophobia) are less often associated with headache and may be less severe even when present. The incidence of nausea and vomiting associated with headache may follow the same pattern.

Those with chronic migraine often report a mixture of ‘tension type’ and migraine headache symptoms. For those with near daily headaches, it is likely not every headache satisfies the  formal definition of migraine. it seems likely that chronic ‘migraine’ is often the overlay of an increasingly severe migraine pattern on a newly emergent ‘tension type’ headache pattern.

Medication overuse

Migraine transformation is frequently, but not always, associated with medication overuse. Not surprisingly, as headache frequency increases, so does the patient’s use of both prescribed and over-the-counter analgesics. Nearly 80% of patients with chronic migraine are reported to overuse medications. As such it has been suggested that excess use of medications, especially over-the-counter medications, might hasten the natural progression of chronic migraine. That seems unlikely, but it is extremely difficult to unravel cause and effect.

By strict classification (as defined by the International Headache Society) medication overuse headache (MOH) represents a separate type of headache altogether (though it can co-exist with migraine.) Technically, in the case of medication overuse, chronic migraine cannot be diagnosed until headache medications have been withdrawn for two months without improvement in headache.

While the prospect of medication withdrawal is not welcome by most with chronic headache, a substantial number of patients do improve after cessation of at least some medications.

It is noteworthy that Americans with migraine spend an estimated $2 billion each year on over-the-counter medications for headache relief, and that while many of these pain relievers have been shown to cause ‘rebound’ headaches leading to medication overuse headaches – none carry warnings to that effect.

Primary vs. Secondary Headache

The vast majority of headache is of ‘benign’ origin. Benign meaning that they are self-limiting (they will eventually go away on their own) and do not indicate that anything ‘worse’ is going on.

Primary Headache:

‘Primary’ headaches are those that do not result from another cause (e.g. intra-cranial bleeding, tumor.)  Differentiating between migraine, tension-type, and cluster headaches (all of which are primary headaches) is important, as optimal treatment may differ. However, more important is knowing when to suspect the possibility of secondary headache.

Secondary Headache:

Secondary headache is headache that is caused by or results from another disease or condition. Any of the following features suggest the possibility of headache as a secondary disorder and warrant further investigation:

  • Unusual history or unusual character of headache.
  • Age over 40 at time of first migraine.
  • Headache is ‘new’, ‘different’ or substantially worse than what has previously been experienced.
  • A change (especially sudden change) in the character of the headache, either in intensity, duration or frequency.
  • Abnormal or unexpected neurological symptoms.
  • Headaches associated with other neurological signs or symptoms (eg, diplopia, loss of sensation, weakness, trouble walking or standing) or those of unusually sudden onset.
  • Headaches that are persistent (especially beyond 72 hours), or that develop after head injury or other trauma.
  • Headaches that are associated with stiff neck or fever.
  • Immediate, very rapid onset of severe headache – sometimes referred to as a “thunderclap headache.”

The “thunderclap headache” typically reaches peak intensity within 60 seconds. Left unattended, it may resolve over several hours – but it should not be left unattended. Thunderclap headache may represent a true medical emergency. In about 25% of cases it is caused by bleeding into the brain that can result in permanent damage or death if not promptly treated. Emergency medical care should be obtained.

One type of bleeding into the brain is called a sub-arachnoid hemorrhage. This almost always results in severe headache – typically described as “the worst headache of my life” and is often associated with a stiff neck, photophobia, nausea, vomiting, and possibly alteration of consciousness. Sub-arachnoid hemorrhage may result in a “thunderclap” headache, or it may develop somewhat more gradually.

Space occupying lesions (e.g. tumors) are another rare cause of headache, but may be missed as the symptoms sometimes mimic those of migraine (but much more often appear as “tension type” headaches.) In a recent extensive study, all patients with tumor-caused headaches that were similar to migraine had unusual symptoms such as excessively long headaches, a dramatic increase in headache frequency, new onset of seizures, confusion, prolonged nausea, and partial paralysis. This again emphasizes the need to investigate unexpected changes in headache frequency, duration or character.

It is important to note that many non-migraine headaches can respond to triptan therapy. Triptans may decrease headache pain associated with viral and bacterial infections and subarachnoid hemorrhage (bleeding into the brain.) When other symptoms raise concerns, the fact that a headache responds to an anti-migraine drug should not be taken as proof that it is a migraine.

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ALL CHRONIC MIGRAINE POSTS

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December 20, 2009

Migraine progression risks – frequency and medication overuse

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Episodic migraine frequency and medication overuse determined as risk factors in progression to chronic migraine.

Progression from episodic migraine to chronic migraine appears to take place in a step-wise fashion, as those with already frequent migraine were found to be at much greater risk of developing chronic migraine. The inclusion of those having 14 migraine days per month might be questioned – as for all practical purposes they already have chronic migraine.

The association with medication overuse is not unexpected – and I’m not sure it tells us much. Of course people use more medication as headache frequency increases. Medication overuse is often described as the use of an acute agent more than twice weekly. Given that those in the high frequency population are having headaches at least 10 times per month (an average of 2.5 times per week) it would be surprising if they were not ‘overusing’ medications for headache.

Most remarkable might be the finding that 14% of all subjects followed developed a chronic pattern within a year. That is substantially higher than reported by other studies.

Findings of the publication below include:

  • 14% of all those followed in this study developed chronic headache (15 days or more, per month, of headache) within one year.
  • The risk of developing chronic headache was 20x greater among those with already frequent headaches (10-14 days per month) vs. those with a low frequency of headache (average of 0-4 days of headache per month).
  • The risk of developing chronic headache were 6x greater among those with already moderate headache frequency (6-9 days per month) vs. those with a low frequency of headache (average of 0-4 days of headache per month).
  • The risk of developing chronic headache was nearly 20x greater when medication overuse was observed.

The publication:

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Neurology. 2004 Mar 9;62(5):788-90.

Incidence and predictors for chronicity of headache in patients with episodic migraine.

Katsarava Z, Schneeweiss S, Kurth T, Kroener U, Fritsche G, Eikermann A, Diener HC, Limmroth V.

Department of Neurology, University Hospital Essen, Germany.

Summary of the abstract

The authors followed 532 consecutive patients with episodic migraine (<15 days/month) for 1 year. Sixty-four patients (14%) developed chronic headache (>/=15 days/month). The odds ratios for developing CH were 20.1 (95% CI 5.7 to 71.5) comparing patients with a “critical” (10 to 14 days/month) vs “low” (0 to 4 days/month) and 6.2 (95% CI 1.7 to 26.6) in patients with an “intermediate” (6 to 9 days/month) vs “low” headache frequency and 19.4 (95% CI 8.7 to 43.2) comparing patients with and without medication overuse.

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November 18, 2009

Chronic migraine in adolescents

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Chronic daily migraine among adolescents not uncommon

Culture strongly affects patient behavior relative to disease. This study, among adolescents in Taiwan, identified approximately 1.5% as having chronic daily headache. While many of those did not meet strict inclusion criteria for migraine, most had migraine features.

Most striking is the extent to which chronic daily headache went untreated. Of 82 students experiencing headache more than 15 days per month, only one was on a preventative medication and only 6 had seen a neurologist.

The publication:

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Neurology. 2006 Jan 24;66(2):193-7.

Chronic daily headache in adolescents: prevalence, impact, and medication overuse.

Wang SJ, Fuh JL, Lu SR, Juang KD.

Summary of the abstract

OBJECTIVES: To examine the prevalence, impact, and related medication use or overuse of primary chronic daily headache (CDH) among adolescents in a field sample.

METHODS: The authors conducted a two-phase CDH survey of all students from ages 12 to 14 years in five selected middle schools in Taiwan. CDH was defined as headache occurring at a frequency of 15 days/month or more, average of 2 hours/day or more, for more than 3 months.

RESULTS: Of the 7,900 participants, 122 (1.5%) fulfilled the criteria for primary CDH in the past year. Girls had a higher prevalence (2.4%) than boys (0.8%).

Twenty-four subjects (20%) overused medications.

Eighty-two (67%) of all CDH subjects had migraine or probable migraine. Only 6 subjects consulted neurologists in the past year, and only 1 subject took headache prophylactic agents.

CONCLUSIONS: Chronic daily headache (CDH) was common in a large nonreferred adolescent sample. A majority of adolescents with CDH had headaches with features of migraine.

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November 17, 2009

Surgery for chronic migraine

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Surgery for migraine unresponsive to medication

Summary of the results

Number who experienced at least a 50% reduction in migraine headache frequency

Actual surgery: 83.7%

Sham surgery (‘placebo’): 57.7%

Complete elimination of migraine headaches

Actual surgery: 57.1%

Sham surgery (‘placebo’): 3.8%

Comment:

The number of patients receiving the surgical procedure (49) is rather small. Nonetheless, this study suggests that for those with significant disability secondary to migraine that is unresponsive to more conservative therapy, surgery might be considered.

The publication:

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Plast Reconstr Surg. 2009 Aug;124(2):461-8.

A placebo-controlled surgical trial of the treatment of migraine headaches.

Guyuron B, Reed D, Kriegler JS, Davis J, Pashmini N, Amini S.

Summary of the abstract

BACKGROUND: Many of the nearly 30 million Americans suffering with migraine headaches are not helped by standard therapies, a proportion of which can harbor undesirable side effects. The present study demonstrates the efficacy of independent surgical deactivation of three common migraine headache trigger sites through a double-blind, sham surgery, controlled clinical trial.

METHODS: Seventy-five patients with moderate to severe migraine headache were studied. Trigger sites were identified (frontal, temporal, and occipital), and patients were randomly assigned to receive either actual or sham surgery. Follow-up was at one year.

RESULTS: Of the total group of 75 patients, 15 of 26 in the sham surgery group (57.7 percent) and 41 of 49 in the actual surgery group (83.7 percent) experienced at least 50 percent reduction in migraine headache (p < 0.05).

Furthermore, 28 of 49 patients in the actual surgery group (57.1 percent) reported complete elimination of migraine headache, compared with only one of 26 patients in the sham surgery group (3.8 percent) (p < 0.001).

Compared with the control group, the actual surgery group demonstrated statistically significant improvements in all validated migraine headache measurements at 1 year. These improvements were not dependent on the trigger site. The most common surgical complication was slight hollowing of the temple in the group with temporal migraine headache.

CONCLUSION: This study confirms that surgical deactivation of peripheral migraine headache trigger sites is an effective alternative treatment for patients who suffer from frequent moderate to severe migraine headaches that are difficult to manage with standard protocols.

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