Migraine sufferers cope with recurrent, incapacitating headaches often accompanied by symptoms such as nausea, vomiting, photophobia, osmophobia, or phonophobia. Of the general population, 6% of men and 15% of women experience migraine, and approximately 2% overall are classified as having chronic migraine. A patient's migraine condition is typically classified as chronic after they experience 15 or more headaches each month for three or more months, and when eight or more of these headaches are categorized as migraines or respond to migraine-specific treatments. Aiding patients who suffer from this common, debilitating neurological condition requires proper diagnosis and a comprehensive management plan coordinated between the primary healthcare provider and a headache specialist.

Providing care for patients with chronic migraine begins with properly identifying the condition, employing approaches that serve to eliminate any exacerbating factors, and fine-tuning a treatment plan. Recent research has suggested that proper diagnosis is not occurring in the majority of cases, with only 20% of patients who fulfill the criteria for chronic migraine ultimately being diagnosed. While diagnosing, it is important to rule out any secondary cause for headaches, and to conduct a thorough health history and examination. Gaining insight into the frequency of headache occurrence is vital, as patients may overlook moderate headaches they have had. Additionally, learning the pattern of use of as-needed medication is necessary, because overuse of medication could be a significant exacerbating factor. Providers should investigate other modifiable risk factors and triggers, including obesity, caffeine consumption, obstructive sleep apnea, psychiatric comorbidities, and even stress. After identifying a patient who has chronic migraine, a comprehensive treatment plan can be offered, including a referral for a neurologist or headache specialist.

Coordinated care delivered by both a patient's headache specialist and primary healthcare provider will allow effective enforcement and monitoring. Measuring the occurrence of migraine and headache is an essential practice and a patient will need to be educated on the use of a headache diary. The information collected will need to be assessed and will be helpful in adjusting the preventative care regimen. Providers can also incorporate the use of disability tools (eg, the Migraine Disability Assessment Score and Headache Impact Test 6) in order to evaluate the full effect of the disease and determine any improvements needed for the treatment plan.

Patients must be educated on how important it is to adhere to the prescribed treatment plan. Since the full benefits of treatment will take time to occur, possibly taking six to eight weeks to show efficacy, they will need guidance to understand what their expectations should be. Providers can help reduce adverse effects by establishing slow titration schedules, and patients can be reassured that some potential adverse effects can lessen over time. As therapy is implemented, patients should be reminded that their condition might have an association with their own environmental, psychological, or internal triggers. A primary healthcare provider can work with a patient to ascertain and modify the risk factors and appropriately address any other comorbidities.

Evidence-based prophylactic drugs for episodic migraine are frequently used to treat chronic migraine. Examples include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, valproate, and OnabotulinumtoxinA; of these, only OnabotulinumtoxinA is approved by the FDA for the prophylaxis of headache in adults with chronic migraine. PDR's Migraine and Tension Headache Management table (content revised in March 2014 using FDA-approved labeling and included as part of the 2015 PDR Nurse's Drug Handbook) offers additional detail on pharmacotherapy for treating headache and migraine. A patient's unique medical background needs to be taken into account to individualize drug selection. Exacerbation of comorbid conditions should be avoided, and depending on tolerance and how well an agent improves the migraine condition or any comorbid disorder, polytherapy may need to be considered.

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Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer
PDR