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  • Review Article
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Chronic migraine—classification, characteristics and treatment

Nature Reviews Neurology volume 8, pages 162–171 (2012)Cite this article

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Abstract

According to the revised 2nd Edition of the International Classification of Headache Disorders, primary headaches can be categorized as chronic or episodic; chronic migraine is defined as headaches in the absence of medication overuse, occurring on ≥15 days per month for ≥3 months, of which headaches on ≥8 days must fulfill the criteria for migraine without aura. Prevalence and incidence data for chronic migraine are still uncertain, owing to the heterogeneous definitions used to identify the condition in population-based studies over the past two decades. Chronic migraine is severely disabling and difficult to manage, as affected patients experience substantially more-frequent headaches, comorbid pain and affective disorders, and fewer pain-free intervals, than do those with episodic migraine. Data on the treatment of chronic migraine are scarce because most migraine-prevention trials excluded patients who had headaches for ≥15 days per month. Despite this lack of reliable data, a wealth of expert opinion and a few evidence-based treatment options are available for managing chronic migraine. Trial data are available for topiramate and botulinum toxin type A, and expert opinion suggests that conventional preventive therapy for episodic migraine may also be useful. This Review discusses the evolution of our understanding of chronic migraine, including its epidemiology, pathophysiology, clinical characteristics and treatment options.

Key Points

  • Chronic migraine is defined as headache on ≥15 days per month for ≥3 months; headaches on ≥8 days per month must fulfill criteria for migraine without aura

  • Treatment requires a multimodal and multidisciplinary approach, including education, behavioral therapy, regular exercise and preventive drug therapy

  • Topiramate and botulinum toxin type A have shown modest but significant efficacy in placebo-controlled trials; other preventive drugs have not been adequately studied for use in chronic migraine

  • Chronic migraine can occur with or without medication overuse; patients with medication overuse should receive advice and support on discontinuation, as well as multidisciplinary treatment for chronic migraine

  • The full therapeutic armamentarium for chronic migraine is best offered in headache referral centers

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Article 13 January 2022

Michel D. Ferrari, Peter J. Goadsby, … David W. Dodick

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Acknowledgements

The authors thank A. O. Horner and P. Kukovich of Imprint Publication Science, for their assistance with the literature search and language editing. They also performed the systematic literature search for Allergan described in the Review criteria. H.-C. Diener acknowledges the support of the German Research Foundation (Deutsche Forschungsgemeinschaft), the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung) and the European Union. D. W. Dodick acknowledges grant support from the National Institute of Neurological Disorders and Stroke (NINDS) and the NIH. P. J. Goadsby has consulted for, advised or collaborated with NINDS, the Netherlands Organization for Scientific Research, the Organization for Understanding Cluster Headaches, and the Organization for the Understanding of Cluster Headache (UK). R. B. Lipton has acted as a reviewer for the National Institute on Aging and NINDS. Professor Lipton acknowledges grant support from the Migraine Research Foundation, the National Headache Foundation, and the NIH (grants PO1AG03949, PO1AG027734, RO1AG025119, RO1AG022374-06A2, RO1AG034119, RO1AG12101, K23AG030857, K23NS05140901A1 and K23NS47256). S. D. Silberstein is on the advisory panel for and receives honoraria from NINDS.

Author information

Authors and Affiliations

  1. Department of Neurology and Headache Center, University Hospital Essen, Hufelandstrasse 55, Essen, 45147, Germany

    Hans-Christoph Diener

  2. Department of Neurology, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, 85054, AZ, USA

    David W. Dodick

  3. Headache Center, University of California San Francisco, 1701 Divisadero Street, Suite 480, San Francisco, 94115, CA, USA

    Peter J. Goadsby

  4. Albert Einstein College of Medicine, Louis and Dora Rousso Building, 1165 Morris Park Avenue, Room 332, Bronx, 10461, NY, USA

    Richard B. Lipton

  5. Department of Neurology 39, Danish Headache Center, Glostrup Hospital, Nordre Ringvej 57, DK-2600, Glostrup, Denmark

    Jes Olesen

  6. Department of Neurology, Thomas Jefferson University, 111 South 11th Street, Suite 8130, Philadelphia, 19107, PA, USA

    Stephen D. Silberstein

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  1. Hans-Christoph Diener
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Contributions

H.-C. Diener, D. W. Dodick and S. D. Silberstein contributed to all aspects of this Review. P. J. Goadsby and J. Olesen contributed to the discussion of content, writing and review and/or editing of the manuscript before submission. R. B. Lipton contributed to the discussion of content and review and/or editing of the manuscript before submission.

Corresponding author

Correspondence to Hans-Christoph Diener.

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Competing interests

H.-C. Diener received honoraria for participation in clinical trials, contribution to advisory boards or oral presentations from Addex Pharmaceuticals, Allergan, Almirall, AstraZeneca, Bayer Vital, Berlin-Chemie, Boehringer Ingelheim, Bristol-Myers Squibb, Coherex Medical, CoLucid Pharmaceuticals, GlaxoSmithKline, Grünenthal, Janssen-Cilag, Johnson & Johnson, Lilly, Medtronic, Merck Sharpe & Dohme, Minster Pharmaceuticals, Novartis, Pfizer, Pierre Fabre, Roche, Sanofi-aventis, Schaper & Brümmer, Weber & Weber and 3M Medica. He also received financial support for research projects from Allergan, Almirall, AstraZeneca, Bayer Healthcare, GlaxoSmithKline, Janssen-Cilag and Pfizer. Dr Diener has no ownership interest in and does not own stocks of any pharmaceutical company.

D. W. Dodick has, within the past 3 years, served on advisory boards and consulted for Alder Biopharmaceuticals, Allergan, Arteaus Therapeutics, Atlas Laboratories & Pharmaceuticals, Autonomic Technologies, Boston Scientific, Bristol-Myers Squibb, Coherex Medical, CoLucid Pharmaceuticals, Ferring Pharmaceuticals, GlaxoSmithKline, Impax Laboratories, Lilly, MAP Pharmaceuticals, Medtronic, Merck Sharpe & Dohme, Nautilus Neurosciences, Neuralieve, NeurAxon, Neurocore, Nevro, Novartis, NuPathe, Pfizer, and Zogenix. He has also received funding for travel, speaking or editorial activities from the Annenberg Center for Health Sciences, Cambridge University Press, CogniMed, IntraMed, Lippincott Williams & Wilkins, Miller Medical Supplies, Oxford University Press, SAGE Publications and Scientiae. Dr Dodick has received research grant support from Advanced Neurostimulation Systems, Boston Scientific, Mayo Clinic, Medtronic and St Jude Medical.

P. J. Goadsby has consulted for, advised or collaborated with Advanced Bionics, Allergan, Almirall, Amgen, Autonomic Technologies, AstraZeneca, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, CoLucid, GlaxoSmithKline, Johnson & Johnson, Lilly, MAP Pharmaceuticals, Medtronic, Merck, Sharpe & Dohme, Neuralieve, NeurAxon, NeuroTherapeutics Pharma and Pfizer.

R. B. Lipton serves as a consultant or advisory board member for, or has received honoraria from, Allergan, American Headache Society, Autonomic Technologies, Boston Scientific, Bristol-Myers Squibb, CogniMed, Diamond Headache Clinic, Endo Pharmaceuticals, GlaxoSmithKline, Lilly, Merck Serono, Nautilus Neurosciences, Neuralieve, Novartis and Pfizer. He also holds stock options in Neuralieve, a company without commercial products.

J. Olesen has received grant or research support, and/or has been a consultant or scientific advisor, and/or has been on the speakers' bureau of the following companies: Bristol-Myers-Squibb, Lundbeck, Merck Serono, NeurAxon, Union Chimique Belge and Zogenix.

S. D. Silberstein is on the advisory panel of and receives honoraria from, Allergan, Amgen, Capnia, Coherex Medical, GlaxoSmithKline, Iroko Pharmaceuticals, Lilly, MAP Pharmaceuticals, Medtronic, Merck Sharpe & Dohme, Neuralieve, NuPathe, Pfizer and St Jude Medical. He is on the speakers' bureau of and receives honoraria from Allergan, Endo Pharmaceuticals, GlaxoSmithKline, Merck Sharpe & Dohme and Zogenix. Dr Silberstein also serves as a consultant for and receives honoraria from Amgen, Nautilus Neurosciences, Novartis, OptiNose and Zogenix.

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Diener, HC., Dodick, D., Goadsby, P. et al. Chronic migraine—classification, characteristics and treatment. Nat Rev Neurol 8, 162–171 (2012). https://doi.org/10.1038/nrneurol.2012.13

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