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Treatment of migraine
Symptoms
Causes
Now what is migrain-
Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.
Keywords: chronic migraine, headache, medication overuse headache, migraine
Introduction
Migraine is a common disabling brain disorder. Headache accounts for 4.4% of all consultations in general practice [Tepper et al. 2004; Kernick et al. 2008b], approximately 5% of all medical admissions to hospital [Weatherall, 2006], and approximately 20% of neurology outpatient consultations [Stone et al. 2010]. Migraine affects over 20% of people at some point in their lives; epidemiological studies have shown that 4.5% of the population of Western Europe has headache on at least 15 days per month [Welch and Goadsby, 2002]; global studies suggest that approximately 1% of the world’s population may have chronic migraine [Natoli et al. 2010]. Chronic migraine imposes a substantial economic burden on society [Buse et al. 2012]. Migraine is so common that, even though for many people it is no more than an inconvenience, the cumulative burden of the disorder caused it to rank in the top 40 conditions causing worldwide disability according to the World Health Organization’s 2012 global burden of disease figures, above all other neurological disorders other than stroke, meningitis and epilepsy; in the United Kingdom it ranks third behind stroke and the dementias, causing the loss of 230,000 DALYs (Disability-Adjusted Life Years) annually [World Health Organization, 2012].
Chronic migraine is the term that the International Classification of Headache Disorders (ICHD) uses to describe patients with frequent headaches, believed to be biologically migrainous [Headache Classification Committee of the International Headache Society, 2013] The meaning of the term ‘chronic migraine’ has evolved over the last two decades, as it has steadily replaced earlier terminology such as ‘chronic daily headache’ and ‘transformed migraine’ [Olesen et al. 2006; Zeeberg et al. 2009; Goadsby et al. 2010]. There is ongoing debate about whether a further subdivision of the diagnosis should be created to specify patients who are refractory to treatment [Martelletti et al. 2014]. The broader acceptance of the concept that migraine can be a chronic condition has led to increasing interest in the pathophysiology, epidemiology, and treatment of this condition [Diener et al. 2012].
Patients with chronic headaches have in the past experienced the adverse effects of lack of education about headaches, and therapeutic nihilism. There is now no excuse for either of these factors to impact upon the management of these patients. As this article will show, it is almost always possible to make a
Diagnosis of chronic migraine
Recognize the pattern
When assessing a patient with chronic headaches (that is, by definition, headaches on at least 15 days per month), it is important from the outset to ascertain how the headaches originally developed. There are two typical patterns. In one set of cases, patients with a pre-existing primary headache disorder (usually, but not exclusively migraine) have ever-increasing attacks until they reach a stage where they do not recover headache freedom in between, a pattern originally called ‘transformed migraine’ [Mathew, 1987; Silberstein et al. 1996]. In the other set of cases, patients start to have a headache one day, and it simply never goes away. This is a syndrome that goes under the name ‘new daily persistent headache’ (NDPH) [Goadsby and Boes, 2002].
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based on collected data..
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