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Chronic migraine: risk factors, mechanisms and treatment

Subjects

Key Points

  • Chronic migraine is a clearly defined subtype of migraine affecting between 1–2% of the general population, yet it receives little attention

  • Chronic migraine usually develops from episodic migraine at a conversion rate of about 3% a year; the chronification is reversible

  • Risk factors for migraine chronification include overuse of acute migraine medication, ineffective acute treatment, obesity, depression, low educational status and stressful life events

  • The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors combined with frequent headache pain lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine

  • Treatment options include pharmacological and nonpharmacological options and neuromodulation

  • Prevention of chronification is essential, and requires adequate treatment of individual migraine attacks, early initiation of preventive medication and avoiding analgesic overuse

Abstract

Chronic migraine has a great detrimental influence on a patient's life, with a severe impact on socioeconomic functioning and quality of life. Chronic migraine affects 1–2% of the general population, and about 8% of patients with migraine; it usually develops from episodic migraine at an annual conversion rate of about 3%. The chronification is reversible: about 26% of patients with chronic migraine go into remission within 2 years of chronification. The most important modifiable risk factors for chronic migraine include overuse of acute migraine medication, ineffective acute treatment, obesity, depression and stressful life events. Moreover, age, female sex and low educational status increase the risk of chronic migraine. The pathophysiology of migraine chronification can be understood as a threshold problem: certain predisposing factors, combined with frequent headache pain, lower the threshold of migraine attacks, thereby increasing the risk of chronic migraine. Treatment options include oral medications, nerve blockade with local anaesthetics or corticoids, and neuromodulation. Well-defined diagnostic criteria are crucial for the identification of chronic migraine. The International Headache Society classification of chronic migraine was recently updated, and now allows co-diagnosis of chronic migraine and medication overuse headache. This Review provides an up-to-date overview of the classification of chronic migraine, basic mechanisms and risk factors of migraine chronification, and the currently established treatment options.

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Figure 1: Multiple factors contribute to migraine chronification.

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Acknowledgements

The authors of this article were supported by the 7th Framework EU-project EuroHeadPain (#602633) and by the German Research Foundation, SFB936/A5 (to A.M).

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Both authors researched the data for the article, provided substantial contributions to discussions of its content, wrote the article and undertook review and/or editing of the manuscript before submission.

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Correspondence to Arne May.

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FURTHER INFORMATION

IHS Classification ICHD-II

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Glossary

Cutaneous allodynia

In cutaneous allodynia, central sensitization to pain causes normally non-noxious tactile stimuli to skin (such as showering, shaving, brushing the hair or wearing tight clothing) to be experienced as painful.

Descending pain-modulating network

A top-down pain modulation system in which brain areas includingthe frontal lobe, hypothalamus and amygdala project on periaqueductal grey, which controls the transmission of nociceptive information in the spinal cord.

Biofeedback

Monitoring of bodily function and responses with biofeedback, such as electromyogram, can help relieve muscle tension and thereby alleviate headache.

Manual therapy

In patients with headache, manual therapy, also known as manipulative therapy — including massage therapy, physiotherapy and spinal manipulative therapy — aims to alleviate headache by relieving muscle tension and increasing mobility of the cervical spine.

Electrical stimulation

Therapeutic options using electrical current, voltage or induction of currents by magnetic fields to influence nerve or muscular functioning.

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May, A., Schulte, L. Chronic migraine: risk factors, mechanisms and treatment. Nat Rev Neurol 12, 455–464 (2016). https://doi.org/10.1038/nrneurol.2016.93

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