Headaches, Migraine (Chronic)

Chronic Migraine Headaches (CM HA)

Diagnosis
-Meets definition of chronic migraines.
–Risk factors reviewed.
-No HA red flags present.
–Differential diagnosis reviewed.
-Workup to get or review: CBC, CMP, TSH. Consider Polysomnography.
-Considered chronic migraine vs medication overuse HA (MOH)
Treatment
–Headache diary: To identify freq, triggers, pattern, associated sx, and response to tx.
-Avoid triggers when possible.
–Abortive treatment options: Use NSAIDs instead of caffeine-combination product.
-Limit acute treatment to 2 times per week. Overuse of abortive med may lead to overuse HA.
-Implement behavioral strategies
-Use preventive medications to make the brain less excitable/reactive.
-Increase preventive medication dose
-Initiate botox (onabotulinumtoxinA) injections.
–Recommend acupuncture.
-Set right expectations. Treatment effect begins in weeks, not days. Framing expectations clearly will make the patient more satisfied with the treatment as they won’t have false hopes.
-Refer to a Headache specialist.

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Sources:

Epocrates