Chronic Migraine

What is chronic migraine?

Migraine is a painful syndrome characterized by pulsating or throbbing headaches, accompanied by sensitivity to light and noise. Nausea and vomiting may also occur, worsening with physical effort and lasting from 4 hours to 3 days.

Types

Migraine is considered chronic when the patient experiences headaches on 15 or more days per month for at least 3 months. People with chronic migraine often overuse painkillers (more than 15 pain pills per month), and tend to have more symptoms of anxiety, depression, and sleep disturbances than those without migraine or with the episodic form. These symptoms are not the cause of migraine, but are very common in chronic migraine patients and can hinder symptom improvement if not properly diagnosed and treated.

Causes

Migraine is genetically determined, and it is very common to find multiple people in the same family affected.
Several known triggers or facilitators include sleeping more or less than usual, going long periods without eating, alcohol consumption, and the approach of the menstrual period in women.

When a migraine attack begins, the brain releases a large amount of stimulating substances that temporarily inflame the blood vessels in the meninges. When attacks become frequent, the brain loses its ability to block this process.

Symptoms

The main symptom is headache on at least 15 days per month for three months. In chronic migraine, the nature of the pain changes compared to the episodic form. As frequency increases, pain intensity tends to decrease, as do symptoms like light and noise sensitivity, nausea, and vomiting. Thus, many chronic migraine patients may experience one or two days of intense migraine-like pain per month, while the remaining episodes are milder or more tolerable — relieved with simple or combined painkillers. This leads to increased medication use, which in turn increases headache frequency — creating a vicious cycle.

Diagnosis

Diagnosis is essentially clinical, based on the characteristics of the pain and associated symptoms.
When the headache is typical and physical and neurological exams are normal, the diagnosis is confirmed.
Imaging tests such as CT scans or MRIs of the brain are not part of the standard diagnosis and should only be performed when the headache changes in nature or is atypical.

Treatment

The goal of chronic migraine treatment is to reduce headache frequency. Preventive treatment involves daily use of medications that reduce headache frequency, not just treat acute attacks. Preventive options include anticonvulsants, beta-blockers, tricyclic antidepressants, and Botulinum Toxin Type A.

The PREEMPT protocol for chronic migraine involves injecting Botulinum Toxin Type A into 31 muscle points around the skull (frontal, temporal, occipital) and in the upper cervical and back regions (paraspinal and trapezius), on both sides of the head.

Results from botulinum toxin treatment begin within the first week and may last 3 to 6 months. Repeated applications, with a minimum interval of 3 months, can lead to better outcomes.

Treatment should be administered by a trained and experienced physician to ensure optimal results and minimize side effects. Facial injections included in the PREEMPT protocol may rarely cause adverse effects such as facial asymmetry or drooping eyelids. When the protocol is followed, the risk of adverse events is minimal. Any side effects are reversible and subside as the toxin’s effect wears off.

Prevention

Daily headaches should not be considered a benign condition, as they significantly reduce quality of life. People with chronic migraine should receive preventive treatment, be able to recognize their triggers, limit painkiller use (no more than 10 to 15 pills per month), and identify and treat symptoms such as anxiety, depression, and insomnia to better manage pain and improve quality of life.

By Einstein Editorial Board