Chronic Migraine: Diagnosis, Characteristics, Lifestyle Modification, Trigger Reduction and Treatment

ABSTRACT

The most prevalent brain condition that impairs function is migraine. A chronic migraine is a very incapacitating disorder that is defined by having a migraine that lasts for at least 10 days every month. Chronic migraine patients commonly visit primary care, are advised to seek treatment in secondary care, and account for a large portion of the patient population in specialized headache clinics. Using a triptan, opioid, compound analgesic, or ergot derivative. A significant, curable cause of neurological impairment is chronic migraine. Making a diagnosis is essential, as is ensuring that any coexisting medical or psychiatric disorders are addressed concurrently with efforts to lessen the biological propensity for headaches. Setting patients’ expectations for what is possible is also crucial. Migraine cannot be “fixed” in any way; it is a hereditary propensity that fluctuates throughout a person’s life.

INTRODUCTION

Migraine is a type of debilitating brain condition, causing moderate to severe headaches on the left side. Statistical figures show, 4.4% of all general practice appointments are for headaches, as are around 5% of medical admissions in hospitals and approximately 20% of outpatients in the neurology department are for migraine only.[1] More than 20% of individuals will experience migraine at some point in their lives, and according to epidemiological research, 4.5% of the population group residing in the West Part of Europe experience headaches, once a month at least. Approximately 1% of the population globally suffers from migraines persistently.[2] The financial toll of chronic migraine on society has also been observed significantly.

The statement made by the International Classification of Headache Disorders states, that those patients experiencing headaches again and again are referred to as physiologically migrainous and also fall under the category of chronic migraine. In the last two decades, the word “chronic migraine” has progressively replaced terms like chronic daily headache and “transformed migraine” changing the meaning of the phrase. There is constant discussion over the need to further subdivide the diagnosis to identify people who are resistant to therapy. Increased interest in the biology, epidemiology, and therapy of migraine has resulted from the idea that it might be a chronic disorder becoming more widely accepted.[3]

Ignorance of headaches and nihilism in treatment is a common factor seen in adversely affected chronic headache sufferers. There is no longer any justification for either of these criteria to affect how these individuals are managed. In individuals with chronic migraine, it is nearly always feasible to make a precise diagnosis, as this article will demonstrate. Once this diagnosis is made, a wide range of therapeutic choices become available.[4]

Diagnosis of chronic migraine

The phenotype is frequently ambiguous in situations of persistent headaches. It is helpful to make the a priori assumptions that individuals seldom need to seek medical advice concerning minor headaches, such as tension-type headaches, and that main headache problems, especially migraine, are more frequently diagnosed by doctors than secondary headaches. When a patient is asked about their first headaches, it is common for them to describe a migrainous condition with episodic headaches that eventually developed into a continuing chronic sickness (often, but not always, brought on by excessive use of painkillers or caffeine psychological conditions like anxiety or depression, physical conditions like sleep apnea, or significant life events). In these situations, chronic migraine is the most probable diagnosis. Although a definitive diagnosis may not always be possible (the ICHD recognizes categories of “probable migraine” and “unclassifiable” headaches), it is reasonable to treat a patient for chronic headaches if they are severe enough to interfere with daily activities and there is no other clear primary or secondary headache diagnosis. This is because chronic migraine is the most likely cause of the patient’s headaches.[5]

A diagnosis should be made, even if it is only a preliminary one; telling the patient what the diagnosis is and assuring them there is not a major primary cause is the primary step in therapy and, in few circumstances, the only action necessary.

CHRONIC MIGRAINE THERAPY

Chronic migraine can be managed in three ways: By lifestyle changes and avoiding triggers, through acute medications (which are administered during acute pain episodes), and through preventative measures (medicine or other treatments aimed at lowering the likelihood of attacks). Although many patients find that changing their lifestyle habits, such as eating regularly and getting enough sleep, helps lessen the frequency of their attacks, individuals with chronic migraine nearly always need to take some sort of medication or other type of therapy. In addition to further consensus recommendations, Guiding principles for diagnosis, prognosis, and treatment of migraine have recently been released for the study of headaches by the British Association for the Study of Headache, the American Headache Society, and the National Institute for Health and Care Excellence (NICE).[6]

Lifestyle modification and trigger reduction

It has been very difficult to determine specific triggers in the population experiencing severe headaches on a regular basis. Defiantly, triggers become more noticeable when persistent headaches are experienced frequently and with therapy they start getting better. Recognizing that this is useful and is simple, but really implementing the necessary modifications is more difficult in nowaday’s busy life. Consistency of routine with time of meals, water, sleep, and stress is constantly beneficial in lowering the susceptibility to migraines. Depression, anxiety, other pain syndromes like fibromyalgia, localized pain in head and neck structures, and situations that put a strain on the “metabolic” system like postural orthostatic tachycardia syndrome or sleep apnea are among the other issues that numerous patients with chronic migraine will show. To optimize the impact of any additional migraine therapies, these must be well managed. Because failing to do so will render the majority of preventative therapy measures unsuccessful, it is especially crucial to identify and manage pharmaceutical abuse (including caffeine misuse).[7]

Acute headache treatments

Acute therapies are beneficial, but in contrast, it is also very difficult to choose a time for taking therapy for patients with migraine. In the early phases of treatment, it may be better to completely restrict the use of acute painkillers due to concerns from both patients and doctors about the potential for prescription misuse. Acute therapy can be restarted when there are distinct “good days” and “poor days” or when there is a persistent headache with distinct exacerbations. The standard rules still hold true: Outbreaks must be handled swiftly while the discomfort is still bearable; use effective dosages; progressively increase treatments up to the highest permissible dose before discontinuing them as ineffective; treatment for corresponding symptoms like nausea is also necessary; and the best delivery mechanism should be chosen (various medications can be given by nasal spray or via a suppository). Triptans should be administered and opiates avoided if at all feasible if straightforward analgesics are ineffective. There are a few possible acute therapies indicated. To prevent making the condition worse by overusing medications, strict guidelines should be created for how frequently acute therapies can be administered.[8]

Preventive treatment

Preventive therapy is often thought of after intensity rises to the stage where it severely affects daily activities like work, school, or social life. This is invariably the case for people who suffer from chronic migraine, and some kind of preventative medicine or other type of intervention is nearly always recommended. However, data from the American Migraine Prevalence and Prevention research indicate that up to 40% of patients who may benefit from prophylactic medicine never receive it, despite their potential need. The effectiveness of many drugs in preventing migraines has been demonstrated. Some of them in the UK do not have the necessary licences for this use. The kind of headaches, comorbidities of the patient, tolerance, teratogenicity, possible side effects, convenience of administration, and patient preference can all have a variable impact on the treatment option. To reduce the chance of adverse effects manifesting, preventive therapies should be started at a low dose. The dosage should be gradually and consistently raised until the drug is effective, unpleasant side effects appear, or a maximum dose is reached, at which time it may be said that the drug is ineffective for that specific patient. Since levels are known to be low, adhesion should be carefully observed. Another preventative measure can be considered at this stage. If the preventative therapy is successful, it should be continued for a while before reducing the dose.[9]

There are few particular tests in individuals with chronic migraine, thus the evidence for using typical preventive drugs frequently requires to be inferred from research in patients with high-frequency episodic migraine.[6] NICE freshly suggested topiramate as the first-line preventive, but most headache specialists still recommend tricyclics (amitriptyline, nortriptyline, or dosulepin), blockers, and agonists as the first line of treatment because they are likely to be equally effective and unquestionably safe (propranolol atenolol, nadolol or metoprolol). If these are unsuccessful, anticonvulsants such as topiramate or sodium valproate may be considered. Flunarizine, a calcium channel blocker, may be helpful.[9]

CONCLUSION

A significant, curable cause of neurological impairment is chronic migraine. Making a diagnosis is essential, as is ensuring that any addressed are co-occurring medical or psychiatric illnesses concurrently with efforts to lessen the biological propensity for headaches. Setting patients’ expectations for what is possible is also crucial. Migraine cannot be “fixed” in any way; it is a hereditary propensity that varies all over a person’s life. Nevertheless, it is manageable and is frequently done so moderately fruitfully by following the guidelines presented in this article.

The future of chronic migraine care is an exciting one. Over the next three to six years, new acute and preventative alternatives, such as antibodies and CGRP (calcitonin gene-related peptide) antagonists, should become accessible. However, there are many ways that patients and professionals may collaborate now to help those with chronic migraine live better lives.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.