Comprehensive review and update on chronic migraine

Heui-Soo Moon

doi:10.5124/jkma.2018.61.5.314

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Moon: Comprehensive review and update on chronic migraine

Original Article

J Korean Med Assoc 2018;61(5):314-322.

Published online: 17 May 2018

DOI: https://doi.org/10.5124/jkma.2018.61.5.314

Comprehensive review and update on chronic migraine

Heui-Soo Moon, MD

Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding author: Heui-Soo Moon E-mail: drmhs0801@gmail.com

Received 14 April 2018 Accepted 28 April 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Chronic migraine (CM) is a common and disabling neurologic disorder. CM is defined as more than 15 days a month over a 3-month period, including at least 8 days per month on which their headaches and associated symptoms meet diagnostic criteria for migraine. Quality of life is highly compromised in patients with this condition, and comorbidities are more frequent than with episodic migraine. The diagnosis requires a carefully-conducted patient interview and neurologic examination, sometimes combined with additional diagnostic tests, to differentiate CM from secondary headache disorders and other primary chronic headaches. CM typically develops from episodic migraine over months to years. Several factors are associated with an increased risk of episodic migraine developing into CM, including the frequent use of abortive migraine drugs. Through identification of risk factors for progression to CM, clinicians can educate patients about modifiable risk factors and can begin appropriate individualized preventive therapy. There is a high frequency of medication overuse in CM. The first step in the management of CM complicated by medication overuse is withdrawal of the overused drugs and detoxification treatment. This article provides an overview of CM, including its epidemiology, risk factors for its development, and information on its pathophysiology, diagnosis, and management.

Keywords: Migraine disorders, Headache disorders, secondary, OnabotulinumtoxinA

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Figure 1.

Differentiating chronic migraine from other primary headaches.

Figure 2.

Fixed sites in Phase 3 PREEMPT (Phase 3 Research Evaluating Migraine Prophylaxis Therapy) study. The anatomic injection sites follow distributions and areas innervated by the trigeminal nerve complex. (A) Anterior injection on corrugator, proceus, and frontalis. (B) Lateral injection on temporalis. (C) Posterior injection on occipitalis, cervical paraspinal, and trapezius.

Table 1.

Chronic migraine diagnostic criteria [2]

Diagnostic criteria
A. Headache (migraine-like or tension-type-like1) on ≥15 day/mo for >3 months, and fulfilling criteria B and C
B. Occurring in a patient who has had at least five attacks fulfilling criteria B to D for 1.1 migraine without aura and/or criteria B and C for 1.2 migraine with aura
C. On ≥8 day/mo for >3 months, fulfilling any of the following:
1. Criteria C and D for 1.1 migraine without aura
2. Criteria B and C for 1.2 migraine with aura
3. Believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
D. Not better accounted for by another ICHD-3 diagnosis.

ICHD-3, the third edition of the International Classification of Headache Disorders.

Table 2.

Medication overuse headache diagnostic criteria [2]

Diagnostic criteria
A. Headache occurring on ≥15 day/mo in a patient with a pre-existing headache disorder
B. Regular overuse^a) for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
C. Not better accounted for by another ICHD-3 diagnosis
ICHD-3, the third edition of the International Classification of Headache Disorders. ^a)Intake of ergotamine, triptans, opioids, combination analgesics (such as tablets that combine simple analgesics with opioids, butalbital, or caffeine), or drugs from multiple drug classes on at least 10 day/mo. Intake of simple analgesics for at least 15 day/mo.

Table 3.

Red flags suggestive of secondary headache disorders [8]

Red flags
Abnormal findings on neurologic examination
Focal neurologic symptoms that are not consistent with typical migraine aura symptoms
Systemic symptoms such as fevers, chills, and weight loss
Orthostatic worsening of symptoms
Exertional worsening of symptoms
New onset headaches after age 50
Thunderclap headaches (very severe headache that reaches maximum intensity in <1 minute)
Headaches in a patient with existing risk factors for a secondary headache (such as cancer or hypercoagulable state)
Pattern change from previous headaches and progression in headache severity

Table 4.

Drug prophylaxis of chronic migraine [3]

List of drugs according to level of evidence
Highest quality evidence (≥2 randomized placebo controlled trials)
Topiramate
Onabotulinumtoxin A
Lower quality evidence (1 randomized study)
Valproate sodium
Amitriptyline
Gabapentin
Tizanidine
Lowest quality evidence (open label study)
Zonisamide
Memantine
Pregabalin

Table 5.

Most effective botulinum injection sites for chronic migraine (PREEMPT injection paradigm)

Muscle	Injection method	Site
Corrugator	5 Units to each side	2
Proceus	5 Units	1
Frontalis	10 Units to each side	4
Temporalis	20 Units to each side	8
Occipitalis	15 Units to each side	6
Cervical paraspinal	10 Units to each side	4
Trapezius	15 Units to each side	6
Total	155 Units	31

PREEMPT, Phase 3 Research Evaluating Migraine Prophylaxis Therapy.

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