An Overview of Chronic Migraine

A.K.A. Transformed Migraine

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Chronic migraine is diagnosed when someone experiences at least 15 migraine attacks per month for at least three months. This disorder is sometimes known as transformed migraine because the migraines are episodic at first. Over time, the attacks "transform" and become more frequent—in some cases almost daily.

Most people with chronic migraine are women, and more than 90 percent have a history of migraine with aura.

transformed migraine
 Illustration by Emily Roberts, Verywell

Symptoms

The primary difference between chronic migraines and episodic migraines is their frequency. The frequency can increase over a period of months or years, depending on a variety of factors that include genetics, lifestyle, life events, and your overall health.

Symptoms of chronic migraines are the same as those of episodic migraines, including a one-sided headache, sensitivity to light, sound, and odors, and nausea; aura is also common among chronic migraine patients. In some cases, the symptoms may become less severe as the migraine transforms from episodic to chronic.

Causes

People with episodic migraine may develop more and more headaches (to the point that the disorder becomes chronic) for various reasons, including hormonal changes, increased stress, or illness; genetics may also be a factor.

According to the National Headache Foundation, nearly 80 percent of those with transformed or chronic migraine overuse medications. This may actually increase the frequency of migraine attacks, and it also can lead to rebound headaches, also known as medication overuse headaches. Drugs that cause medication overuse headaches are those that are used for acute (as opposed to preventive) migraine pain relief.

Overuse is defined by the number of days an acute medication is taken per month and depends on the drug, but 10 to 15 days of use per month is considered enough to cause problems.

There are several drugs associated with medication overuse headaches, including, but not limited to, triptans, ergotamines, opioids, and even over-the-counter analgesics like Tylenol (acetaminophen) and nonsteroidal anti-inflammatories, like Advil (ibuprofen).

People who have headaches, especially migraines, have a tendency to develop medication overuse headaches even if they are using the analgesics for other medical conditions.

Diagnosis

If your primary care doctor suspects that you may have chronic migraine, he or she will probably recommend that you see a neurologist, a doctor who specializes in disorders of the brain and nervous system, including migraine. Because the neurologist will diagnose chronic migraine based on your symptoms and the pattern of your headaches, most of the initial visit will involve talking rather than a detailed physical examination.

Among the important information to share with your doctor:

  • The number of migraines you've had in the past three months
  • A list of the medications you are currently taking
  • Medications that help your migraines—and those that don't
  • How many days per month you take medications for acute pain relief

Keeping a diary of each migraine—the date it occurred, triggers, symptoms, and how you treated it—can be very useful.

There are no lab tests used to diagnose chronic migraine. In some cases, a doctor may want to do a magnetic resonance imaging (MRI) or a computed tomography (CT) scan, but these are used mainly for patients who have never had headaches before.

Treatment

There is no cure for chronic migraines or any other type of migraines, but it is a manageable condition when you find the right treatment.

The only medication that is approved by the U.S. Food and Drug Administration (FDA) specifically for chronic migraine is Botox (onabotulinum A), which has been shown to reduce the number of hours of headache per month by about a third and can also reduce the severity of symptoms when they occur.

Botox is administered by injection in different areas of the head and neck, where it enters nerve endings and blocks the release of chemicals involved in pain transmission. Patients typically get injections every 12 weeks.

Otherwise, treatments for chronic migraines are the same as those used for the episodic form of the condition, including:

  • Non-steroidal anti-inflammatories (NSAIDs), such as Advil (ibuprofen) and Aleve (naproxen sodium)
  • Triptans, including Imitrex (sumatriptan) and Zomig (zolmitriptan)
  • Antiemetics (anti-nausea medications)
  • Dihydroergotamines, including Migranal (D.H.E.)
  • Dexamethasone
  • Intranasal lidocaine
  • Antihypertensives (blood pressure lowering agents), such as metoprolol, propranolol, and timolol
  • Antidepressants, such as Elavil (amitriptyline) and Effexor (venlafaxine)
  • Anticonvulsants: These include valproate products, divalproex sodium, sodium valproate, and Topamax (topiramate)

There are also several neuromodulation devices that have been approved for migraine treatment by the FDA. They include:

  • Transcutaneous supraorbital neurostimulator (tSNS), a.k.a. Cefaly
  • Single-pulse transcranial magnetic stimulator (springTMS, sTMS)
  • Non-invasive vagal nerve stimulator (nVNS), a.k.a. gammaCore

Alternative treatments—including acupuncture, massage, and certain herbs and supplements—may be helpful for preventing and treating migraines. Furthermore, many find lifestyle measures, such as meditation, exercising, avoiding certain foods, and getting enough sleep, an important part of their overall care.

If you have a chronic migraine that's complicated by frequent rebound headaches, your doctor may recommend stopping all medications for a while. This may stop your chronic headaches and can make the drugs more effective once you resume taking them.

Coping

When you have a migraine, it is difficult, if not impossible, to work, study, or conduct any of the routine activities of daily life. Add to that the fact that attacks typically last between four and 72 hours (and in some cases as long as a week), and it’s not surprising that migraine in general is one of the top 20 most disabling illnesses—with chronic migraine being that much more so. 

In addition, many people who have transformed or chronic migraine feel isolated and suffer from symptoms of depression and anxiety.

Because migraine disease is so prevalent, numerous online and in-person support groups are available for patients as well as their families and caregivers. Your healthcare practitioner can help you find support groups, as can the American Migraine Foundation website.

A Word From Verywell

Chronic migraine is a challenging illness. It's important to be vigilant about identifying and avoiding triggers and to seek your doctor's advice if your episodic migraines become chronic. Fortunately, there are numerous treatment options that can allow you to live a full and productive life with this condition. 

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