Dr Nicole Limberg, MBBS, FRACP
The Brisbane Headache and Migraine Clinic has been in close collaboration with Dr Nicole Limberg in assisting chronic migraine sufferers. Chronic Migraineurs often require a holistic approach in order achieve the best outcome for their condition, and we are happy to have Dr Nicole Limberg assist in managing and treating our patients. Dr Limberg is one of the few neurologists in Australia who specialises solely in chronic migraines.
Patients with chronic migraine represent the most severe, and disabled segment of the migraine spectrum. Specialist help, with a Neurologist who has a particular interest in Headache and Migraines, would be of benefit for most of these patients.
Essentially, a patient with chronic migraine is a patient with migraine who has progressed to a very frequent headache pattern. When these patients are asked, ‘On how many days a month are you completely headache free?’, the answer will often indicate that the patient has more headache days a month than initially thought, as patients may not have been considering their milder headache days.
These frequent headaches need not all have migrainous features (ie pulsating, one sided pain, light and noise sensitivity, and or nausea), and as noted can be somewhat milder in nature. Diagnosis by a Neurologist is an important step in management, for if the patient is incorrectly diagnosed with chronic tension type headache, then management will not be suitable.
Central sensitization of the pain systems likely plays an important role in the development of chronic migraine, and these patients have been shown to have diminished pain thresholds on sensory testing, as compared to subjects without this condition.
Risk factors for progression to chronic migraine include obesity, caffeine overuse, stressful life events, and acute medication overuse. Head and neck injuries can also cause rapid transformation of episodic migraine to chronic migraine.
As patients with chronic migraine have very frequent headaches, many fall into acute migraine medication overuse. Opioid containing medications are a powerful cause of medication overuse headache, and it is argued that these medications should never be used in migraine. It has been shown that giving patients information and advice about medication overuse headache can reduce headache frequency and acute medication use.
At Migraine Specialist a Neurologist will perform a thorough history, and physical examination, and this is required to make a diagnosis of chronic migraine. In addition, neuroimaging may be required in some patients. Other forms of chronic daily headache will also be considered by the Neurologist, including chronic tension headache, new daily persistent headache and hemicrania continua.
Important to the management of chronic migraine are behavioural aspects of care, prevention and management of medication overuse, as well as acute and preventative medication management.
Behavioural Factors for Successful Management of Chronic Migraine Include:
- Pacing activities to avoid triggering or exacerbating migraine
- Self monitoring to identify factors that influence migraine
- Managing migraine triggers effectively
- Practicing good stress management skills including relaxation techniques
- Having regular meals, good weight management and nutrition
- Exercising regularly
- Reducing caffeine use to no more than 1 cup of coffee per day
- Maintaining healthy sleep habits including regular sleep times and adequate sleep
In general, the most effective medications for treatment of acute attacks are the triptans. Non steroidal anti-inflammatories (NSAIDs) are also important acute medications. Anti-nausea drugs are also helpful if nausea is a significant problem. As mentioned, opioid medications are best avoided where possible.
Given the high headache frequency of patients with chronic migraine, acute medications are not usually sufficient to control attacks, and medication overuse headache is a constant risk. Essentially all patients with chronic migraine warrant serious consideration for migraine medication protection (prophylaxis).
Several treatment options are available, including injection therapy. The American Academy of Neurology has concluded that injection therapy is safe and effective in reducing the number of headache days per month in chronic migraine and has recommended that it should be offered as a treatment option to patients with chronic migraine. It is important to note that the administration of injection therapy for chronic migraine prevention is best provided by a Neurologist who has undergone further specialist protocol training.
Patients with chronic migraines should be referred to a Neurologist with an interest in Headache and Migraine treatment, who can provide a comprehensive management plan. It is important that relatively new and effective chronic migraine treatments, such as injection therapy, be made available to these patients. In the near future, the same will likely be true for the emerging therapies of anti-calcitonin-gene-related-peptide-therapies, currently in development.
Written by Dr Nicole Limberg, MBBS, FRACP
Director of Migraine Specialist
The Diagnosis and Management of Chronic Migraine in Primary Care, Headache: The Journal of Head and Face Pain; Becker MD, Vol 57 (9), Oct 2017, 1471-1481