Chronic Migraine: Recognition, Prevention, and Treatment

Abstract & Commentary

By Dara G. Jamieson, MD, Associate Professor of Clinical Neurology, Weill Cornell Medical College. Dr. Jamieson reports she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil; and is on the speaker's bureau for Boehringer Ingelheim and Merck. This article originally appeared in the October 2008 issue of Neurology Alert. It was edited by Matthew Fink, MD, and M. Flint Beal, MD.

Synopsis: Increased migraine attack frequency and overuse of acute medication, especially barbiturates and opiates, are risk factors for the chronification of migraine, which occurs in up to 2% of individuals.

Sources: Bigal ME, et al. Chronic migraine in the population: burden, diagnosis, and satisfaction with treatment. Neurology. 2008;71:559-566; Bigal ME, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48:1157-1168; Silberstein S, et al. Epidemiology, risk factors, and treatment of chronic migraine: a focus on topiramate. Headache. 2008;48:1087-1095.

Chronic daily headache is a heterogeneous group of headache disorders characterized by headaches on ≥ 15 days per month for more than three months. Chronic or transformed migraine, a subtype of chronic daily headache, has a prevalence of up to 2% of individuals, predominantly women, in the United States. Bigal et al used longitudinal data from the American Migraine Prevalence and Prevention (AMPP) study to evaluate the disease burden, diagnosis, and risk factors associated with chronic migraine. Analysis of the AMPP study found that patients with chronic migraine reported significantly more missed days of work and family activities than did patients with episodic migraine. While the majority of the chronic migraine sufferers (87.6%) sought care to discuss their headaches with a health professional, migraine-specific acute treatments were used by less than a third of chronic migraineurs, and less than half were satisfied with their acute therapies. Only a third of chronic migraineurs were using preventive medications.

Data from the AMPP study was used to assess the role of specific classes of acute medications in the chronification of migraine. Adjustment was made for risk factors for headache progression, such as gender, headache frequency and severity, and prevention medication use. Of 8219 individuals with episodic migraine in 2005, 209 (2.5%) had developed transformed migraine by 2006. Baseline increased headache frequency was a risk factor for transformed migraine. Individuals who used medications containing barbiturates (OR = 2.06, 95% CI = 1.3-3.1) or opiates (OR = 1.98, 95% CI = 1.4-2.2) were at increased risk of transformed migraine. A dose-response relationship was found for use of barbiturates. Use of triptans (OR = 1.25, 95% CI = 0.9-1.7) at baseline was not associated with prospective risk of transformed migraine. Overall, NSAIDs (OR = 0.85, 95% CI = 0.63-1.17) were not associated with transformed migraine. NSAIDs appeared to be protective against transition to transformed migraine in migraineurs with less than 10-14 headache days per month, but were associated with an increased risk of transition to transformed migraine at high levels of monthly headache days. The risk of migraine chronification was greater in women than in men, even controlling for triptan use and headache frequency. The authors concluded that episodic migraine sufferers develop transformed migraine at the rate of 2.5% per year. Any use of barbiturates and opiates, but not triptans, was associated with increased risk of chronic migraine. NSAIDs were protective at low headache frequency, but increased the risk of transformation at high headache frequency.

Multiple medications, including topiramate, have been found to be effective and safe for preventive treatment for episodic migraine. These medications also may be used to decrease the frequency and severity of chronic migraine. Two randomized, double-blind, placebo-controlled, multicenter trials investigating the efficacy and safety of topiramate in the treatment of patients with chronic migraine found that topiramate, at a dose of 100 mg daily, reduced the number of headache days and the use of acute medications.


Migraine can evolve from an episodic annoyance to a chronic disability, a process that often is abetted by well meaning but misguided health care providers who provide inappropriate quantities of non-specific acute pain medications. The recognition of the potential dangers of excessive acute medication use, especially with barbiturates and opiates, and the appropriate use of preventive medications in patients with frequent migraines, can decrease the incidence of chronic migraine. Prevention of the excess use of acute pain medication in combination with the use of daily prophylactic medication, such as topiramate, can decrease the disability of chronic migraine.