Chronic Migraine - UpToDate

1/4/2020 Chronic migraine - UpToDate
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Chronic migraine
Authors: Ivan Garza, MD, Todd J Schwedt, MD, MSCI
Section Editor: Jerry W Swanson, MD, MHPE
Deputy Editor: John F Dashe, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2020. | This topic last updated: May 22, 2019.
INTRODUCTION
Chronic daily headache is a descriptive term that encompasses several different specific headache
diagnoses characterized by frequent headaches. Chronic daily headache types with individual
headaches of long duration (ie, four hours or more) include chronic migraine, chronic tension-type
headache, medication overuse headache, hemicrania continua, and new daily persistent headache.
This topic will discuss chronic migraine (previously known as transformed migraine). Other types of
chronic daily headache are reviewed elsewhere. (See "Overview of chronic daily headache".)
PATHOPHYSIOLOGY
The pathophysiology of migraine centers on the trigeminovascular system. This is discussed in detail
separately. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults",
section on 'Pathophysiology'.)
Although the pathophysiology of the transformation from episodic to chronic migraine is not well-
understood, it is hypothesized that atypical pain processing, cortical hyperexcitability, neurogenic
inflammation, and central sensitization are involved [1]. Furthermore, in patients with migraine,
functional and structural alterations in the brain have been identified that correlate with longer disease
duration and increased headache frequency [2,3]. However, it is not clear whether these alterations
lead to chronic migraine. They may be simply markers of transformation or secondary effects from
frequent migraines.
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EPIDEMIOLOGY
Chronic migraine affects approximately 2 percent of the world population [4]. It causes significant
reductions in quality of life and is even more disabling than episodic migraine [5-8]. In addition,
chronic migraine results in enormous expense to society. In the United States, the direct and indirect
costs of migraine are estimated to be more than 20 billion dollars annually, and a significant proportion
of this cost is attributable to chronic migraine [9].
Through a process known as "migraine transformation," some patients with an episodic migraine
pattern (<15 headache days a month) transition to a chronic migraine pattern (≥15 headache days a
month) [10]. Among patients with episodic migraine, transformation to chronic migraine occurs in
approximately 3 percent per year [11].
Non-modifiable risk factors for the transformation from episodic to chronic migraine include the
following [1,12-18]:
Female sex
Genetic makeup
History of head or neck injury
Low education level
Low socioeconomic status
Stressful life events (eg, divorce, job loss)
Younger age
High baseline headache frequency
Presence of cutaneous allodynia
Psychiatric disorders
Comorbid pain disorders
Potentially modifiable risk factors for this transformation include [1,12-16,18,19]:
Overuse of abortive headache medications

Habitual snoring
High caffeine consumption
Obesity
Sleep disorders
Low efficacy of acute migraine treatment
Further study is needed to determine if altering modifiable risk factors decreases the rate of
transformation from episodic to chronic migraine.
Patients who develop chronic migraine may revert to episodic migraine, as discussed below. (See
'Prognosis' below.)
CLINICAL FEATURES
Many patients with chronic migraine have daily or near daily low to moderate intensity headaches and
mild migrainous features with superimposed severe intensity headaches with more prominent
migrainous features such as photophobia, phonophobia, osmophobia, nausea, vomiting, and
cutaneous allodynia (ie, the perception of pain produced by innocuous stimulation of normal skin).
(See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on
'Clinical features'.)
Comorbid conditions — In observational studies, patients with chronic migraine have a high
frequency of comorbid psychiatric disorders, sleep disorders, fatigue, other types of pain, and
gastrointestinal complaints; migraine is also associated with a small increase in the absolute risk of
ischemic stroke [20-27].
In one study, psychiatric comorbidities among 152 patients with transformed migraine included
major depression, dysthymia, panic disorder, and generalized anxiety disorder, observed in 57,
11, 30, and 8 percent, respectively [21].
In another study of 63 patients with chronic migraine, two-thirds meet criteria for chronic fatigue
syndrome [22].
In a report of 101 patients with transformed migraine, the diagnostic criteria for fibromyalgia were
fulfilled by 36 percent [23].
In a sample of 1283 migraineurs who presented for evaluation to a tertiary headache clinic,
patients with chronic migraine slept less than those with episodic migraine and were more likely
to report difficulty falling and staying asleep [24].
Among 150 patients with chronic migraine complicated by probable medication overuse
headache, the most common comorbidities were psychiatric and gastrointestinal, identified in 76
and 43 percent, respectively [25].
Accumulating evidence supports an association between migraine, particularly migraine with

aura, and ischemic stroke risk. However, the absolute increase in the risk of stroke is small.
Migraine may also be associated with an increased risk for other forms of cardiovascular disease
such as myocardial infarction. These relationships are discussed separately. (See "Headache,
migraine, and stroke", section on 'Migraine and stroke risk'.)
Recognition and treatment of these comorbidities can result in improved health, greater quality of life,
and may potentially result in higher migraine treatment success rates.
DIAGNOSIS
The diagnosis of chronic migraine depends upon a consistent clinical history without evidence for
another primary or secondary headache disorder.
The diagnostic criteria for chronic migraine required the presence of headache for 15 or more days
per month for more than three months, with the features of migraine headache present on at least
eight days per month (table 1) [28]. These criteria allow for the inclusion of migraine headaches that
are treated early after the onset, prior to the development of typical migraine characteristics, when
they may resemble tension-type headaches.
Chronic migraine (table 1) must be differentiated from other forms of chronic daily headache, such as
chronic tension-type headache (table 2), hemicrania continua (table 3), new daily persistent headache
(table 4), and secondary headaches. (See "Overview of chronic daily headache".)
MANAGEMENT
The treatment of chronic migraine should focus on prophylactic therapy while avoiding migraine
triggers and minimizing the use of acute headache medications [1]. Prophylactic interventions may
include pharmacotherapy, behavioral therapy, physical therapy, and other strategies. Management
often requires the simultaneous use of these different therapeutic modalities.
Identification and treatment of comorbid disorders is also important. (See 'Comorbid conditions'
above.)
Acute headache medication intake should be limited in order to avoid medication overuse headache,
but severe superimposed migraine headaches are treated in the same manner as episodic migraine
headaches. (See "Acute treatment of migraine in adults" and "Preventive treatment of migraine in
adults".)
Patients and clinicians should have realistic treatment expectations with regard to chronic migraine.
The overall goal is control of headaches as opposed to eradication. It is reasonable to expect
reductions in headache frequency and/or severity with a well-considered treatment plan.
The treatment of status migrainosus (a debilitating migraine attack lasting for >72 hours) with
intravenous dihydroergotamine is discussed separately. (See "Medication overuse headache:
Treatment and prognosis", section on 'Dihydroergotamine'.)
Pharmacotherapy — Preventive medications for chronic migraine treatment are less well-studied
than they are for episodic migraine. In addition, some of the available controlled trials evaluating
treatment of chronic migraine are limited by one or more methodologic problems, such as small size,
inclusion of patients with overuse of acute headache medications, high dropout rates, concomitant
use of other prophylactic medications, and/or lack of a specific headache diagnosis [29].
First-line agents — In clinical practice, the same prophylactic medications used for episodic
migraine are used for the prevention of chronic migraine. Thus, based mainly upon their efficacy and
tolerability when treating episodic migraine (see "Preventive treatment of migraine in adults"), first-line
prophylactic medications for chronic migraine include:
Propranolol
Amitriptyline
Topiramate [30,31]
Valproic acid and its derivatives for men (and for women who do not have childbearing potential)
We suggest that treatment for patients with chronic migraine begin with trials of one of these agents. It
is expected that up to 50 percent of patients treated with one of these medications will have at least a
50 percent reduction in the frequency of headaches after three months of treatment, given adequate
doses. However, side effects are common and may limit the use of these prophylactic agents.
Topiramate has at least two randomized placebo-controlled trials supporting their use for chronic
migraine prophylaxis [30-32]. There is lower quality evidence for chronic migraine prophylaxis with
sodium valproate, gabapentin, tizanidine, amitriptyline, atenolol, memantine, zonisamide, and
pregabalin [33-40]. Nevertheless, some of these agents (eg, propranolol, amitriptyline) are considered
first-line for chronic migraine treatment based upon clinical experience and strong data supporting
their benefit in episodic migraine.
Second- and third-line agents — For patients with chronic migraine that is refractory to adequate
trials of first-line agents, a number of other drugs are potential alternatives, including the following:
Second-line agents:
• Botulinum toxin type A (onabotulinumtoxinA)

• CGRP antagonists (erenumab, fremanezumab, and galcanezumab)
• Verapamil
• Other beta blockers (atenolol, nadolol, metoprolol, timolol)
• Gabapentin
• Magnesium
• Riboflavin
• Candesartan
• Other tricyclic antidepressants (nortriptyline, protriptyline)
Third-line agents:
• Feverfew
• Tizanidine [33]
• Memantine
• Pregabalin
• Cyproheptadine
• Zonisamide
There is evidence from randomized controlled trials supporting the efficacy of botulinum toxin and
CGRP antagonists for chronic migraine (see 'Botulinum toxin' below and 'CGRP antagonists' below).
The effectiveness of the remaining second-line medications for episodic and chronic migraine is
uncertain, as most have been studied only on a limited basis. (See "Preventive treatment of migraine
in adults", section on 'Calcium channel blockers' and "Preventive treatment of migraine in adults",
section on 'Other agents'.)
We suggest the use of second-line agents for the prevention of chronic migraine when first-line drugs
have failed, and third-line agents when first-line and second-line agents have failed. These
recommendations are based upon our clinical experience. Like first-line agents, the choice among the
second- and third-line drugs depends upon individual patient factors, as discussed in the next section.
Botulinum toxin — While earlier randomized trials evaluating botulinum toxin injection for
chronic migraine (≥15 headache days a month) or chronic daily headache yielded mixed results [41-
43], the findings from two relatively large 24-week multicenter randomized controlled trials (PREEMPT
1 AND PREEMPT 2) suggest that botulinum toxin type A (onabotulinumtoxinA, Botox) is effective for
the treatment of chronic migraine [44,45]. Although the two PREEMPT trials used the same methods,
they had different primary outcome measures.
In PREEMPT 1, there was no significant difference between groups for the primary outcome,
frequency of headache episodes. However, onabotulinumtoxinA treatment was superior to
placebo on some secondary outcome measures including the frequency of headache days and
migraine days [44].
In PREEMPT 2, onabotulinumtoxinA treatment resulted in a larger reduction in number of

headache days (the primary outcome measure) compared with placebo. OnabotulinumtoxinA
was also superior to placebo on several secondary outcomes [45].
Pooled analyses of data from the PREEMPT 1 and PREEMPT 2 trials, which together enrolled
1384 adults, found statistically significant differences favoring onabotulinumtoxinA for a decrease
in the frequency of headache days relative to baseline (the same primary outcome as PREEMPT
2) and for nearly all secondary outcomes except the frequency of acute headache pain
medication intake [46,47]. The rate of treatment discontinuation due to adverse events was
higher for botulinum toxin than for placebo (3.8 versus 1.2 percent).
There was a large response to placebo treatment in these trials, and the difference between
onabotulinumtoxinA injection and placebo for many of the outcomes was modest, even if
statistically significant [44-46]. As an example, in the pooled analysis, treatment with
onabotulinumtoxinA led to a statistically significant reduction of headache days per 28 days
compared with placebo (8.4 versus 6.6), but the absolute difference between the two groups was
small (1.8 days) [46].
A majority (approximately 66 percent) of patients in both PREEMPT trials were overusing

analgesic medications [44,45]. (See "Medication overuse headache: Etiology, clinical features,
and diagnosis".)
Overall, these and other data support the utility of botulinum toxin injection as moderately superior to
placebo for the treatment of chronic migraine [48,49]. However, several factors have led us to
consider it as second-line therapy. These include the need for an experienced clinician to administer
onabotulinumtoxinA, its high cost, and the policies of most insurance companies that limit
reimbursement for onabotulinumtoxinA only for patients who fail or are unable to tolerate other
prophylactic medications.
CGRP antagonists — Migraine treatments using monoclonal antibodies targeting the calcitonin
gene-related peptide (CGRP) ligand or its receptor have reached the stage of regulatory approval.
However, given their high cost, insurance coverage stipulations, and lack of real-world long-term
safety data, we consider erenumab, fremanezumab, and galcanezumab as second-line, even though
there is high-quality evidence for their efficacy and short-term safety. (See 'Pharmacotherapy' above
and "Preventive treatment of migraine in adults", section on 'CGRP antagonists'.)
CGRP is a therapeutic target in migraine because of its role in mediating trigeminocervical pain
transmission and the vasodilatory component of neurogenic inflammation (see "Pathophysiology,
clinical manifestations, and diagnosis of migraine in adults", section on 'Role of calcitonin gene-
related peptide').
A randomized controlled trial of 1130 adults with chronic migraine evaluated fremanezumab, a
humanized monoclonal antibody that selectively binds to CGRP [50]. The trial randomly assigned
subjects in a 1:1:1 ratio to subcutaneous injections of fremanezumab quarterly, fremanezumab
monthly, or matching placebo. At 12 weeks, fremanezumab was modestly effective for reducing
the average number of headache days per month (4.3 days for the fremanezumab quarterly
group, 4.6 days for fremanezumab monthly group, and 2.5 days for the placebo group).
Fremanezumab was approved for the preventive treatment of migraine in adults by the US Food
and Drug Administration (FDA) in September 2018 [51]. (See "Preventive treatment of migraine
in adults", section on 'Fremanezumab'.)
In a randomized, placebo-controlled trial of over 600 patients with chronic migraine,

subcutaneous erenumab, a monoclonal antibody that inhibits the CGRP receptor, was effective
for reducing migraine days [52]. Erenumab may also be modestly effective for prevention of
episodic migraine, as discussed separately (see "Preventive treatment of migraine in adults",
section on 'CGRP antagonists'). Erenumab was approved for migraine prevention by the FDA in
May, 2018 [53].
Another controlled trial of 1113 adults with chronic migraine evaluated galcanezumab, a
humanized monoclonal antibody to the CGRP ligand [54]. Participants were randomly assigned
to monthly subcutaneous injections in a 1:1:2 ratio of galcanezumab 120 mg (with a 240 mg
loading dose), galcanezumab 240 mg, or placebo. At three months, reductions in the mean
number of monthly migraine headache days were greater for galcanezumab 120 mg and
galcanezumab 240 mg compared with placebo (-4.8 and -4.2, versus -2.7 for placebo).
Galcanezumab was approved for migraine prevention by the FDA in September 2018. (See
"Preventive treatment of migraine in adults", section on 'Galcanezumab'.)
The CGRP monoclonal antibodies were generally well-tolerated in these clinical trials. Injection site
reactions and hypersensitivity reactions were the most commonly observed adverse effects. Potential
adverse effects of the CGRP monoclonal antibodies related to pregnancy or breast-feeding are
unknown.
Choosing an agent — The choice of specific prophylactic agent for either episodic or chronic
migraine depends upon individual patient factors, including the presence of comorbid conditions such
as medical disorders, psychiatric disorders, sleep disorders, fatigue, other types of pain, and
gastrointestinal complaints. As an example, tricyclics or other antidepressants may be preferred for
patients who are depressed or prone to depression. On the other hand, beta blockers may be
preferred for patients with hypertension. However, with some preventive agents, the doses used to
treat migraine are insufficient to treat comorbid conditions. Thus, dosing may need to be adjusted if
the intent is to treat a comorbid condition.
Regardless of the drug chosen, application of certain principles may improve the success rate of
prophylactic migraine therapy and reduce complications:
Start oral drugs at a low dose and increase gradually

Give the chosen medication an adequate trial
Avoid overuse of acute headache medications
Avoid valproate for women of childbearing potential unless it is essential to management and
alternative therapies are not appropriate
Address patient expectations and preferences
These points are discussed in greater detail elsewhere. (See "Preventive treatment of migraine in
adults", section on 'Principles of preventive therapy'.)
Nonpharmacologic therapy — Nonpharmacologic forms of therapy may be useful for the treatment
of chronic migraine. Modalities include behavioral therapy (eg, biofeedback, cognitive-behavioral
therapy, stress management, relaxation therapy), physical therapy (eg, exercise, heat, cold packs,
electrical stimulation), and neurostimulation. In addition, therapeutic lifestyle changes (eg, good sleep
hygiene, routine meal schedules, regular exercise) and avoidance of migraine triggers are often
advocated for patients with chronic migraine. However, there is a paucity of high-quality studies
examining the role of nonpharmacologic interventions specifically for chronic migraine.
Avoidance of migraine triggers — Patients with chronic migraine are more likely to have
headaches triggered by stress, not eating, odors, neck pain, smoke, sleeping late, and exercise than
patients with episodic migraine [55]. These are discussed in detail separately. (See "Pathophysiology,
clinical manifestations, and diagnosis of migraine in adults", section on 'Precipitating and exacerbating
factors'.)
Avoidance of specific migraine triggers may reduce the frequency of headaches in patients with
chronic migraine. Of course, patients with continuous headaches are less likely to be able to
determine specific migraine triggers than those who have episodic headaches.
Behavioral and physical therapy — In agreement with guidelines for migraine headache (mainly
based upon studies of episodic migraine) from the American Academy of Neurology (AAN) published
in 2000 [56], we suggest the use of behavioral therapy for migraine prevention. Options include
relaxation training, thermal biofeedback combined with relaxation training, electromyographic
biofeedback, or cognitive-behavioral therapy. The choice among these interventions should be
individualized according to factors that include clinician familiarity, local availability and expertise, and
patient preference.
In our clinical experience, physical therapy may be useful for the treatment of chronic migraine in
patients who have constant muscle tension or in those who report onset of muscle tension preceding
migraine headaches. Of note, the AAN guidelines concluded that evidence-based recommendations
could not be made regarding the use of hypnosis, acupuncture, transcutaneous electrical nerve
stimulation, chiropractic or osteopathic cervical manipulation, occlusal adjustment, or hyperbaric

oxygen [56].
Both behavioral therapy and physical therapy may be combined with each other and/or with
preventive drug therapy [57].
Neurostimulation
Transcranial magnetic stimulation — Limited observational evidence suggests that single-

pulse transcranial magnetic stimulation (sTMS) may be effective for migraine prevention, but high
cost and limited insurance coverage are barriers to its use. sTMS is reviewed separately. (See
"Preventive treatment of migraine in adults", section on 'Transcranial magnetic stimulation'.)
Transcutaneous supraorbital nerve stimulation — There is evidence from at least one small
randomized-controlled trial that supraorbital transcutaneous electrical nerve stimulator is
beneficial for migraine prevention, as reviewed elsewhere. (See "Preventive treatment of
migraine in adults", section on 'Transcutaneous supraorbital nerve stimulation'.)
Occipital nerve stimulation — There are inconsistent data from small randomized trials
regarding the benefit of occipital nerve stimulation for the treatment of chronic migraine [58,59]. In
the largest trial, there was no significant difference at 12 weeks for the primary endpoint, the
percentage of patients that had a ≥50 percent reduction in mean daily pain score in the active
compared with the control group [59]. However, there were statistically significant if modest
improvements with active stimulation for a number of secondary endpoints, including the
percentage of patients with a ≥30 percent reduction in mean daily pain score, and reduction in
the mean number of headache days and migraine-related disability. The findings from these
reports are limited by concerns about blinding in the control (sham treatment) groups, given that
active treatment causes paresthesia, and relatively high rates of complications, including lead
migration in 14 to 24 percent of subjects [58-61]. Further trials are needed to determine if
occipital nerve stimulation is a useful therapy for chronic migraine.
PROGNOSIS
Chronic migraine may revert to episodic migraine over time in 26 to 70 percent of patients [62,63].
The largest study, conducted by mailed questionnaire, followed 383 respondents with chronic
migraine [63]. After two years, chronic migraine had remitted to either low frequency episodic
migraine (≤9 headache days/month), other episodic headache, or no headache in 26 percent.
Predictors of remission were lower baseline headache frequency and absence of cutaneous
allodynia.
Another report evaluated 136 patients with transformed (ie, chronic) migraine who presented to a
specialty headache clinic and were followed for one year [62]. Reversion to episodic migraine
from transformed migraine was observed in 95 patients (70 percent). Predictors of reversion
included complete withdrawal of overused medications, compliance with prophylactic medication
regimens, and regular physical exercise.
Some patients have a pattern of moving in and out of a chronic migraine state over time [1,18].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Migraine and other primary headache
disorders".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The
Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth
information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-
mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
Basics topics (see "Patient education: Migraines in adults (The Basics)")
Beyond the Basics topics (see "Patient education: Migraines in adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Through a process known as "migraine transformation," some patients with an episodic migraine
pattern transition to a chronic migraine pattern (≥15 headache days a month). (See
'Epidemiology' above.)
Many patients with chronic migraine have daily or near-daily headaches of low to moderate
severity. Superimposed on this baseline are exacerbations of pain with more prominent
migrainous features. (See 'Clinical features' above.)
Observational evidence suggests that patients with chronic migraine have a high frequency of
comorbid psychiatric disorders, sleep disorders, fatigue, other types of pain, gastrointestinal
complaints, cerebrovascular disease, and cardiovascular disease. (See 'Clinical features' above.)
The diagnosis of chronic migraine depends upon a consistent clinical history and exclusion of
secondary headache disorders (table 1). Chronic migraine also must be differentiated from other
forms of long-duration primary chronic daily headache, including chronic tension-type headache
(table 2), hemicrania continua (table 3), and new daily persistent headache (table 4). (See
'Diagnosis' above.)
The management of chronic migraine should focus on prophylactic therapy and avoidance of
acute headache medication overuse. Prophylactic interventions may include pharmacotherapy,
behavioral therapy, physical therapy, lifestyle modification (good sleep hygiene, routine meal
schedules, regular exercise), and avoidance of migraine triggers. Management often requires the
simultaneous use of these different therapeutic modalities. (See 'Management' above.)
For patients with chronic migraine who desire pharmacologic treatment, we suggest a trial with
one of the first-line prophylactic migraine medications (Grade 2B). First-line prophylactic agents
are propranolol, amitriptyline, and topiramate; valproic acid and its derivatives are first line for
men and for women who do not have childbearing potential. The choice among migraine
prophylactic agents depends upon individual patient factors and comorbid conditions. (See 'First-
line agents' above and 'Choosing an agent' above.)
Second-line pharmacologic agents for chronic migraine include botulinum toxin injections, CGRP
antagonists (erenumab, fremanezumab, and galcanezumab), verapamil, other beta blockers,
gabapentin, magnesium, riboflavin, candesartan, and other tricyclic antidepressants. Third-line
agents include feverfew, tizanidine, memantine, pregabalin, cyproheptadine, and zonisamide.
Botulinum toxin injections are modestly superior to placebo for the treatment of chronic migraine.
The remaining drugs have been studied only on a limited basis, and their effectiveness in
migraine prophylaxis is uncertain. For patients with chronic migraine who have failed treatment
with first-line agents, we suggest use of onabotulinumtoxinA injections (Grade 2B),
subcutaneous erenumab, fremanezumab, or galcanezumab (Grade 2B), or other second-line
agents (Grade 2C). Third-line agents are alternatives for those who fail treatment with first and
second-line agents. (See 'Second- and third-line agents' above.)
For patients with chronic migraine who desire nonpharmacologic therapy, we suggest behavioral
therapy (Grade 2C). Options include relaxation training, thermal biofeedback combined with
relaxation training, electromyographic biofeedback, or cognitive-behavioral therapy. As with
medications, the choice among these interventions should be individualized. (See 'Behavioral
and physical therapy' above.)
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Topic 3337 Version 32.0
GRAPHICS
Chronic migraine diagnostic criteria
Description:
Headache occurring on 15 or more days per month for more than three months, which has the features of migraine
headache on at least eight days per month.
Diagnostic criteria:
A. Headache (tension-type-like and/or migraine-like) on 15 or more 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 the following criteria for migraine without aura
(B1) and/or migraine with aura (B2)
B1. Migraine without aura:
B1a. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
B1b. Headache has at least two of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
B1c. During headache at least one of the following:
Nausea and/or vomiting

Photophobia and phonophobia
B2. Migraine with aura:
B2a. One or more of the following fully reversible aura symptoms:
Visual
Sensory
Speech and/or language
Motor
Brainstem
Retinal
B2b. At least two of the following characteristics:
At least one aura symptom spreads gradually over ≥5 minutes

Two or more aura symptoms occur in succession
Each individual aura symptom lasts 5 to 60 minutes
At least one aura symptom is unilateral
At least one aura symptom is positive
The aura is accompanied, or followed within 60 minutes, by headache
C. On eight days or more per month for more than three months, fulfilling any of the following:
Criteria B1b and B1c for migraine without aura

Criteria B2a and B2b for migraine with aura
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
ICHD-3: International Classification of Headache Disorders, 3rd edition.
Data from: Headache Classification Committee of the International Headache Society (IHS) The International Classification of
Headache Disorders, 3rd edition. Cephalalgia 2018; 38:1.
Graphic 56064 Version 10.0

Chronic tension-type headache diagnostic criteria
Description: A disorder evolving from frequent episodic tension-type headache, with daily or very frequent episodes of
headache, typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting hours to days, or
unremitting. The pain does not worsen with routine physical activity, but may be associated with mild nausea,
photophobia or phonophobia.
A. Headache occurring on ≥15 days per month on average for more than three months (≥180 days per year) and
fulfilling criteria B through D
B. Lasting hours to days, or unremitting

C. At least two of the following characteristics:
1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
1. No more than one of photophobia, phonophobia or mild nausea
2. Neither moderate or severe nausea nor vomiting
E. Not better accounted for by another ICHD-3 diagnosis
ICHD-3: International Classification of Headache Disorders, 3rd edition
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache
Disorders, 3rd edition. Cephalalgia 2018; 38:1.
Hemicrania continua diagnostic criteria
Description:
Persistent, strictly unilateral headache, associated with ipsilateral conjunctival injection, lacrimation, nasal congestion,
rhinorrhea, forehead and facial sweating, miosis, ptosis and/or eyelid edema, and/or with restlessness or agitation.
The headache is absolutely sensitive to indomethacin.
A. Unilateral headache fulfilling criteria B to D
B. Present for more than three months, with exacerbations of moderate or greater intensity
C. Either or both of the following:
1. At least one of the following symptoms or signs, ipsilateral to the headache:
Conjunctival injection and/or lacrimation

Nasal congestion and/or rhinorrhea
Eyelid edema
Forehead and facial sweating
Miosis and/or ptosis
2. A sense of restlessness or agitation, or aggravation of the pain by movement
D. Responds absolutely to therapeutic doses of indomethacin
E. Not better accounted for by another ICHD-3 diagnosis
Data from: Headache Classification Committee of the International Headache Society (IHS). The International Classification of
New daily persistent headache diagnostic criteria
Description:
Persistent headache, daily from its onset, which is clearly remembered. The pain lacks characteristic features, and
may be migraine-like or tension-type-like, or have elements of both.
A. Persistent headache fulfilling criteria B and C
B. Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours
C. Present for more than three months
D. Not better accounted for by another ICHD-3 diagnosis
Data from: Headache Classification Committee of the International Headache Society (IHS). The International Classification of

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1/4/2020 Chronic migraine - UpToDate

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Potentially modifiable risk factors for this transformation include [1,12-16,18,19]:

Overuse of abortive headache medications

Accumulating evidence supports an association between migraine, particularly migraine with

Treatment and prognosis", section on 'Dihydroergotamine'.)

• Botulinum toxin type A (onabotulinumtoxinA)

In PREEMPT 2, onabotulinumtoxinA treatment resulted in a larger reduction in number of

A majority (approximately 66 percent) of patients in both PREEMPT trials were overusing

In a randomized, placebo-controlled trial of over 600 patients with chronic migraine,

Start oral drugs at a low dose and increase gradually

stimulation, chiropractic or osteopathic cervical manipulation, occlusal adjustment, or hyperbaric

Transcranial magnetic stimulation — Limited observational evidence suggests that single-

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INFORMATION FOR PATIENTS

Basics topics (see "Patient education: Migraines in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

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Topic 3337 Version 32.0

Chronic migraine diagnostic criteria

B1. Migraine without aura:

B1a. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)

B1b. Headache has at least two of the following characteristics:

B1c. During headache at least one of the following:

Nausea and/or vomiting

B2. Migraine with aura:

B2a. One or more of the following fully reversible aura symptoms:

B2b. At least two of the following characteristics:

At least one aura symptom spreads gradually over ≥5 minutes

Criteria B1b and B1c for migraine without aura

D. Not better accounted for by another ICHD-3 diagnosis

ICHD-3: International Classification of Headache Disorders, 3rd edition.

Graphic 56064 Version 10.0

Chronic tension-type headache diagnostic criteria

B. Lasting hours to days, or unremitting

2. Pressing or tightening (non-pulsating) quality

3. Mild or moderate intensity

4. Not aggravated by routine physical activity such as walking or climbing stairs

D. Both of the following:

1. No more than one of photophobia, phonophobia or mild nausea

2. Neither moderate or severe nausea nor vomiting

E. Not better accounted for by another ICHD-3 diagnosis

ICHD-3: International Classification of Headache Disorders, 3rd edition

Graphic 68892 Version 5.0

Hemicrania continua diagnostic criteria

C. Either or both of the following:

1. At least one of the following symptoms or signs, ipsilateral to the headache:

Conjunctival injection and/or lacrimation

2. A sense of restlessness or agitation, or aggravation of the pain by movement

D. Responds absolutely to therapeutic doses of indomethacin

E. Not better accounted for by another ICHD-3 diagnosis

ICHD-3: International Classification of Headache Disorders, 3rd edition.

Graphic 62652 Version 4.0

New daily persistent headache diagnostic criteria

C. Present for more than three months

D. Not better accounted for by another ICHD-3 diagnosis

ICHD-3: International Classification of Headache Disorders, 3rd edition.

Graphic 76010 Version 5.0

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