Treatment of Chronic Migraine

Abstract

Chronic migraine is defined in different ways. The most commonly used definition is headache on more than 15 days per month in patients with migraine. Chronic migraine is difficult to treat and requires a multidisciplinary approach. Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. Many other substances have been investigated in chronic daily headache. All trials were underpowered and, therefore, recommendations concerning possible efficacy are not possible.

Rationale for use of onabotulinum toxin A (BOTOX) in chronic migraine

“…The management of CM is challenging and sometimes frustrating, and requires a multimodal-multidisciplinary approach including education, behavioral therapy, and pharmacological prophylaxis [3]. The patient should be encouraged to lose weight, increase physical activity, reduce caffeine, alcohol, and analgesic intake, and reduce stress, get regular sleep, and meals; medical or psychiatric comorbidities should be carefully recognized and treated.…”

“…The patient should be encouraged to lose weight, increase physical activity, reduce caffeine, alcohol, and analgesic intake, and reduce stress, get regular sleep, and meals; medical or psychiatric comorbidities should be carefully recognized and treated. Different pharmacological preventive treatments, in most cases with limited supporting evidence, have been considered for CM, ranging from anticonvulsants (topiramate, sodium valproate, gabapentin, pregabalin, and zonisamide) to antidepressants (amitriptyline, fluoxetine), beta-blockers (atenolol), myorelaxants (tizanidine), and memantine [3]. At present, onabotulinum toxin A (BoNT-A) is the only drug approved for CM prophylaxis by the American Food and Drug Administration and the European Medicines Agency [4].…”

Best Practices for Patients With Chronic Migraine

“…6 Improving the diagnosis of chronic migraine, eliminating/ minimizing exacerbating factors, and optimizing treatment can substantially reduce the personal and global burden. 7,8 …”

“…41 Drug selection should be individualized on the basis of the patient's overall medical profile, avoiding treatments that may exacerbate a comorbid condition (eg, flunarizine and b-blockers, which may potentially exacerbate depression). 7,42,43 However, patients with tachycardia or hypertension may find b-blockers helpful in treating the headache disorder and the comorbid cardiovascular disorder. 31 When a single agent does not sufficiently improve both the migraine and the comorbid disorder or is not well tolerated, polytherapy should be considered.…”

Chronic Daily Headache

“…About 47.1% of onabotulinumtoxinA-treated patients experienced at least this degree of improvement, whereas only 35.1% of placebo-treated patients had achieved this degree of improvement. 15 According to Diener and colleagues, 16 the use of topiramate and local injection of onabotulinumtoxin are the only treatments of CM supported by adequately powered placebo-controlled randomized trials. Several medication trials have been underpowered, and/or the follow-up period is too short to be clinically relevant in patients with chronic headaches.…”