Chronic Migraine: When Migraine Becomes a Daily Burden — Causes and Modern Treatment

Episodic migraine — attacks occurring fewer than 15 days per month — affects approximately 10–12% of Indians. But chronic migraine — 15 or more headache days per month, with at least 8 of those meeting migraine criteria, for more than 3 months — is a more severe and disabling condition affecting an estimated 2–3% of the population. The transition from episodic to chronic migraine is largely preventable, yet most patients do not recognise the warning signs until they are already trapped in a daily headache cycle.

How Episodic Migraine Becomes Chronic

The primary driver of chronification is medication overuse. When migraine patients use acute medications (paracetamol, triptans, NSAIDs, opioids) on more than 10–15 days per month, the medication itself begins to cause headache — medication overuse headache (MOH), also called rebound headache. The brain becomes sensitised to headache in response to medication withdrawal. Other risk factors for chronification: untreated or undertreated migraine attacks; sleep disorders; obesity; caffeine overuse; stressful life events; depression and anxiety (bidirectional relationship — migraine and mood disorders each worsen the other).

Treatment of Chronic Migraine

Preventive medication is mandatory: topiramate (50–100mg at night), amitriptyline (10–75mg), propranolol, valproate, or flunarizine. These reduce headache frequency by 50% in most responders — but must be taken daily for 3–6 months before full effect is judged.

OnabotulinumtoxinA (Botox): Injected into 31 points across the head and neck every 12 weeks. NICE-approved and evidence-based for chronic migraine. Reduces headache days by 8–9 per month. Now available in Hyderabad.

CGRP monoclonal antibodies (erenumab, fremanezumab): Monthly subcutaneous injections targeting the CGRP pathway — the most recent advance in migraine prevention. Highly effective with minimal side effects. Increasingly available in India.

MOH withdrawal: If medication overuse is present, the overused medication must be withdrawn — this is uncomfortable but essential. Guided withdrawal in a structured programme achieves significantly better outcomes. Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.