Chronic Migraine - Essential Information

Patient Expert
Teri Robert

In the United States, there are more than 37 million people who have migraine disease. Of those, it is estimated that between 2 to 4 million have chronic migraine, which means that they have a migraine or headache more often than not.2

What is chronic migraine?

In the simplest of terms, chronic migraine (CM) is defined as: "Headache occurring on 15 or more days per month for more than three months and has the features of migraine headache at least eight days per month."1

For diagnosing and classifying migraine and other headache disorders, the International Headache Society's (IHS) International Classification of Headache Disorders, 3rd Edition (ICHD-3), is considered the gold standard. In 2013, the IHS Classification Committee revised and released ICHD-3 with the following criteria for chronic migraine:

Diagnostic criteria1

A. Headache (tension-type-like and/or migraine-like) on 15 days per month for more than three months and fulfilling criteria B and C

B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for migraine without aura and/or criteria B and C for migraine with aura

C. On eight days per month for more than three months, fulfilling any of the following:

1. Criteria C and D for migraine without aura
2. Criteria B and C for 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.

The burden and impact of chronic migraine

Studies have revealed data about the difference in the impact of CM when compared to that of episodic migraine (EM):

  • Based on the MIDAS questionnaire (The Migraine Disability Assessment Test), the impact of CM is significantly greater than that of episodic Migraine (EM).

  • Over a three-month period:4

  • 8.2 percent of those with CM reported missing at least five days of work as compared to 2.2 percent of those with EM.

  • 33.8 percent of those with CM reported at least five days of reduced productivity at work as compared to 2.2 percent of those with EM.

  • 58.1 percent of those with CM reported at least five days of reduced productivity in household work as compared to 18.2 percent of those with EM.

  • 36.9 percent of those with CM reported at least five days of missed family activities as compared to 9.5 percent of those with EM.

Chronic migraine and stigma

In a study designed to "characterize stigma in patients with chronic and episodic migraines," researchers found:5

  • Participants with CM scored higher on the Stigma Scale for Chronic Illness scale (SSCI) than participants with EM.
  • Participants with CM also scored significantly higher on the SSCI than a mixed panel of patients with chronic neurologic diseases; stroke, epilepsy, multiple sclerosis, Alzheimer’s, ALS and Parkinson’s disease.

Chronic migraine and social anxiety disorder (social phobia)6

  • Research has shown social anxiety disorder to be more prevalent in adults with migraine than adults without migraine.
  • In adolescents "chronic migraine is strongly associated with high social anxiety score, regardless of demographic data and pain intensity. The total burden of migraine may be increased with social anxiety disorder co-morbidity."

Utilization of health care resources in the U.S. and Canada 8

The most common medical services utilized include:

  • Migraine-specific medications
  • Health care provider visits
  • Emergency room visits
  • Diagnostic testing.

In the U.S.:

  • 26.2 percent of chronic migraine participants reported visiting a primary care physician in the preceding three months vs. 13.9 percent of episodic migraine participants.
  • Total mean migraine-related costs for participants with chronic migraine in the U.S. were $1,036 over three months compared to $383 for persons with episodic migraine.

In Canada:

  • 48.2 percent of chronic migraine participants had visited a primary care physician, compared with 12.3 percent of episodic migraine subjects.
  • Total mean headache-related costs among chronic migraine subjects were $471 compared to $172 for episodic migraine subjects.

Treating chronic migraine

At this point, there are no acute, preventive, or rescue medications that have been developed specifically for the treatment of chronic migraine. For prevention of CM, treatment usually begins with the same medications used for the prevention of episodic migraine.

Although it was developed for other conditions, onabotulinumtoxinA (Botox) was approved by the FDA for the treatment of chronic migraine in 2010. It is the only medication that's been approved by the FDA for treating CM. It was not found effective for EM. When considering Botox for CM, it's essential to work with a physician who has been trained to administer Botox for CM, as the specific injections protocol is vital to the success of the treatment. The protocol is for 31 injections in the areas shown below:

The same acute and rescue medications used for EM are also used for CM. Due to the frequency of migraine and headache days in CM, it's exceedingly difficult to treat every migraine or headache day.

Using Migraine abortive medications and / or pain relievers more than two or three days a week can lead to medication overuse headache  (MOH).  Unfortunately, even people who are aware of MOH often don't realize that alternating different types of medications doesn't reduce the risk of MOH. Medication-overuse headache attributed to multiple drug classes not individually overused has been defined as:

"Regular intake of any combination of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids on a total of 10 days per month for more than three months without overuse of any single drug or drug class alone."

Most migraine specialists recommend limiting the use of these medications to no more than two or three days per week. ummar The burden of living with chronic migraine, the stigma associated with it, and the health care utilization and costs are even more significant than that of episodic migraine.

Treating chronic migraine can present a huge challenge for both the migraineur and their health care team. Trying preventive treatments can take a great deal of time and patience. The good news is that there are now more than 100 preventive treatments available.

Many people with chronic migraine find it necessary to work closely with a migraine and headache specialist. It's vital to realize that neurologists aren't necessarily migraine and headache specialists, and migraine and headache specialists aren't necessarily neurologists. (See Migraine and Headache Specialists - What's So Special?) If you need help finding a migraine specialist, check the “Find a Health Care Specialist” section on the ACHE website.

One of the most important aspects of living with chronic migraine is hope. Dr. Peter Goadsby expressed this very well when I talked with him about being better treatment partners. He said:


Chronic migraine can indeed go back to episodic.  By partnering with a good migraine and headache specialist, I was able to go from chronic migraine to episodic — twice. The first time, we were able to get my migraines down to an average of one per month. That lasted for several years until other health issues caused me to discontinue one of my preventive medications and reduce the dosage of another. Within a few months, I was back to CM with 25 headache and migraine days in one month. Yes, I was heartbroken, but I was also determined, Now I am averaging eight days per month. We must not lose hope.

1 Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808  10.1177/0333102413485658

2 Silberstein, Stephen D., MD. "Managing Chronic Migraine in 2011: Background." Medscape Neurology. April 18, 2011.

3 Natoli, JL; Manack, A; Dean, B; Butler, Q; Turkel, CC; Stovner, L.; and Lipton, R.B. "Global prevalence of chronic Migraine: A systematic Review." Cephalalgia 2010;30: 599. DOI: 10.1111/j.1468-2982.2009.01941.x.

4 Bigal ME, Serrano D, Reed M, Lipton RB. "Chronic Migraine in the population: burden, diagnosis, and satisfaction with treatment." Neurology. 2008;71(8):559-566. DOI 10.1212/01.wnl.0000323925.29520.e7.

5 Park J.E.1; Kempner J.2; Young W.B. "The Stigma of Migraine." Poster presentation. 52nd annual meeting of the American Headache Society. Los Angeles. June, 2010.

6 Manrusha, Marcelo R.; Lin, Jaime; Minett, Thais S. C.; Vitalle, Marie Sylvia de S.; Fishberg, Mauro; Vilanova, Luiz Celso P.; Peres, Mario F. P. "Social anxiety score is high in adolescents with chronic Migraine." Pediatrics International vol. 54 no. 3 393-396.

7 Rothrock, John F. "Botox-A for Suppression of Chronic Migraine: Commonly Asked Questions." Headache. Volume 52, Issue 4, April 2012, Pages: 716–717. doi: 10.1111/j.1526-4610.2012.02121.

8 Stokes, Michael, MPH; Becker, Werner J., MD; Lipton, Richard B., MD; Sullivan, Dean H., PhD; Wilcox, Teresa K., PhD; Wells, Leandra, PhD; Manack, Aubrey, PhD; Prokorovsky, Irina, MSc; Gladstone, Jonathan, MD; Buse, Dawn C., PhD; Varnon, Sepideh F., PhD; Goadsby, Peter J., MD, PhD; Blumenfield, Andrew M., MD. "Cost of Health Care Amont Patients with Chronic and Episodic Migraine in Canada and the USA: Results from the International Burden of Migraine Study." Headache 2011;51:1058-1077. doi: 10.1111/j.1526-4610.2011.01945.x

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