Chronic Migraine:
Observations from a Referral
Headache Center
President and CEO, The Carolina Headache Foundation, Chapel Hill , NC
Director, Carolina Headache Institute , Chapel Hill, NC
Professor, University of North Carolina
Contractor for Defense and Veteran Brain Injury Centers
TNS Ft Worth 2015
Disclosures
• With regards to this talk the speaker has no
financial conflicts to Disclose
– In the course of this talk I will mention off label
use of medications
– THE ARE NO APPROVED TREATMENTS FOR MANY
OF THE HEADACHES I WILL DISCUSS
CHRONIC DAILY HEADACHE
4.1% of 13,000
General
Public
Scher Al et al. Headache. 1998.
Sanin LC et al. Headache. 1993.
30%-80%
Headache Clinic
Population
1.5.1 Chronic migraine (ICHD-II +/- R1)
New entrant to classification
A. Headache fulfilling criteria C and D for
1.1 Migraine without aura on 15 d/mo for >3 mo
B. Not attributed to another disorder
©International Headache
Society 2003/5
1.3 Chronic migraine (ICHD-3 beta)
A. Headache (TTH-like and/or migraine-like) on ≥15 d/mo for >3
mo and fulfilling criteria B and C
B. In a patient who has had ≥5 attacks fulfilling criteria B-D for 1.1
Migraine without aura and/or criteria B and C for 1.2 Migraine
with aura
C. On ≥8 d/mo for >3 mo fulfilling any of the following:
1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. believed by the patient to be migraine at onset and relieved
by a triptan or ergot derivative
D. Not better accounted for by another ICHD-3 diagnosis
Which of which is Chronic Migraine?
10
5
0
Never goes away
10
5
0
Never goes away
Comes and Goes
Is it a matter of scale?
Or Factors?
Modifiable
Non-modifiable (?)
Triggers (?)
Gender/Age
Medication use (?overuse)
Mood states/comorbidities
BMI (?)
Trauma including abuse/neglect and
PTSD
Sleep (snoring) (?)
Concurrent illness –
immune/inflammatory
Neck Pain (?)
Comorbidites
?
?
Distinguish Primary from
Secondary Headache Disorders
Headache
No
Diagnosis
Red Flags
Primary
Headache
Yes
Secondary
Headache
Atypical
Features
Investigations
Step 1: Exclude Secondary Headache
History and examination
Screen for red flags SNOOP4
Assess for worrisome signs and symptoms
Look for atypical features
Systemic symptoms (fever, weight loss) or
Secondary risk factors (HIV, cancer)
Neurologic symptoms or signs
Onset: abrupt, peak <1 min
Older: >50 (GCA; glaucoma)
Previous headache history (new or change)
Postural, positional
Precipitated by Valsalva, exertion, etc
Papilledema
Yes
Evaluate for
secondary
headache
5-minute Examination of
Headache Patient
• Vitals - every patient needs them (BP, temp, BMI)
• Head and neck
– Palpate (skull base, TMJs, temporal arteries, upper cervical
facets, pericranial muscles, paranasal sinuses)
– Listen (auscultate the head, orbits, and neck)
• Focused neurological examination
– Talk to patient (mental status), watch them walk
– Cranial nerves (fundi, visual fields, ocular motility, facial
symmetry, palate/tongue)
– Upper motor neuron exam (arm extensor and leg flexor
strength, DTRs, plantar responses)
Diagnostic Criteria for Migraine vs.
Tension-type Headache
Migraine
Tension-type
Frequency
Variable
Variable
Duration
4-72 H
30 min – 7 days
Location
Unilateral (40% bilateral)
Bilateral
Description
Pulsating (50% nonpulsating)
Pressing/tightening
(nonpulsating)
Intensity
Moderate-severe
Mild-moderate
Effect of routine
physical activity
Aggravated by or cause
avoidance of
Not aggravated by
Nausea or vomiting
Yes
No
Photophobia or
phonophobia
One or both
No more than one
Attributable
Not attributable to another
disorder
Not attributable to
another disorder
Headache Classification Subcommittee of the IHS. ICHD-III (beta). Cephalalgia. 2013; March.
Step 2: Identifying Primary
Headache Syndrome
Identify primary
headache
syndrome
Episodic headache frequency
<15 days/month
(eg, migraine)
Episodic short duration
headache <4 hours or
multiple discrete episodes
Chronic headache
frequency
≥15 days/month
Episodic long duration
headache
lasting >4 hours
Migraine
Tension-type
Progressive Headache
• When episodic migraine progresses, chronic migraine is the
most likely diagnosis
– Evolution of EM to CM
 2.5% per year in general population
• When is diagnostic testing necessary in progressive
headache?
– Not always…Consider a therapeutic trial
• What is considered an adequate workup?
– Neuroimaging?
– Lumbar puncture?
– Laboratory testing?
Comfort Signs that a Chronic Headache
Condition is NOT Secondary Headache
•
•
•
•
•
•
•
Long duration of illness
Typical clinical features
Family history of similar primary headache
Typical treatment response
Normal neurological examination
Menstrual exacerbations
Evolution of EM to CM with medication overuse
Differential Diagnosis of Primary Chronic Headache of
Long Duration
Hemicrania
Continua
Frequency
New Daily
Persistent HA
Chronic
Tension Type
Chronic
Migraine
≥15 day/month ≥15 day/month ≥15 day/month ≥15 day/month
2-72 hours (H);
constant or
intermittent
4-72 H;
constant or
intermittent
Duration
Continuous
Constant or
intermittent
Pain
Hemicranial;
steady ache;
some
throbbing
Like migraine
or tension type Like TH;
headache
tightening
(TTH); pressure
Like migraine;
throbbing
Associated
symptoms
Ipsilateral,
autonomic
features
Variable
None
Nausea,
photophobia,
Phonophobia
Treatment
response
Indomethacin
Variable
Variable
Variable
Patient Characteristics of EM vs CM
Patient Characteristics
Headache frequency,
days/month
Report Severe
headache pain (%)
Duration of headache
pain without
medication (mean h)
Duration of headache
pain with medication
(mean h)
Episodic Migraine
Chronic Migraine
<15
≥15
78.1
92.4*
38.8
65.1*
12.8
24.1*
Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2
Sociodemographic characteristics
EM
CM
Race (% white)
Women, %
87.3
80.0
90.7
78.6
Low household income (% < $22,500/year)
24.9
29.9*
Comorbidities
Depression, %
Anxiety, %
Obesity, %
Cutaneous allodynia, %
17.2
18.8
21.0
63.2
30.2*
30.2*
25.5*
68.3*
Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2
TREATMENT: FDA Approved
Acute Management of Migraine Prevention of EM
Propranolol (tablets,
liquid)
Triptans (oral, nasal, injectable,
transdermal): almotriptan,
Timolol (tablets)
eletriptan, frovatriptan, naratriptan,
Divalproex sodium ER
rizatriptan, sumatriptan,
Sodium valproate
zolmitriptan
Topiramate
Prevention of CM
OnabotulinumtoxinA injections
Dihydroergotamine mesylate
(tablets, nasal sprays)
Diclofenac potassium oral solution
Transcutaneous
Supraorbital
NeuroStimulation (tSNS)
headband
Headache: The Journal of Head and Face Pain pages 103-122, 6 FEB 2015 DOI: 10.1111/head.12505_2
Current treatments
• Neurotoxins
• Medications
– Episodic migraine prevention for chronic
migraine?
• Procedures
– The worst of the worst?
• Multidisciplinary
• Neil Raskin
– “You are intractable”
Acute Medication Overuse
• A diagnosis of “Medicationoveruse Headache” (MOH) is
NOT synonymous with
medication overuse
• Acute medication overuse is a
behavior, defined by days of
medication talking
• MOH is headache attributed to
the overuse of medications
Frequent
Attacks
“Rebound”/
medication-overuse
headache
Acute
therapy
Treatment of suspected MOH involves the discontinuation of
the overused medication(s) and initiation of preventive therapy
Figure Rates and odds ratios of transition from EM to CM by treatment efficacy category in the
fully adjusted model (model 3)CI = confidence interval; CM = chronic migraine; EM = episodic
migraine; OR = odds ratio.
Richard B. Lipton et al. Neurology 2015;84:688-695
© 2015 American Academy of Neurology
Step 3:
Step 2:
Step 1:
Diagnose specific Identify primary
Exclude secondary
headache
headache syndrome headache
disorder
Complete history and examination
Assess headache signs and
symptoms & look for atypical features
Screen for red flags
SNOOP
If headache frequency & severity
are progressing, watch for and warn
against risks for chronic migraine
Yes
No
Identify primary headache syndrome
Episodic headache of
long duration
frequency <15 d/m >4
hours
Migraine
Migrainous
Tension-type
Chronic headache of
long duration
frequency ≥15 d/m
headache lasting >4
hours
Chronic migraine
Chronic tension-type
NDPH
Hemicrania continua
Evaluate for
secondary
headache
Yes
Assess for acute
medication overuse
Refractory Headache
•
•
•
•
Continuous Headache
New Daily Persistent Headache
Side Locked Headache
Focal Headache
– With migraine features
– Without migraine features
• Stress and Distress
Headache Index
In the last 28 days I had (write a best guess number in each blank
below):
_______ Days where my worst headache was severe
+_______ Days where my worst headache was moderate
+_______ Days where my worst headache was mild
+_______ Days with absolutely no headache, neck discomfort,
facial/ jaw discomfort whatsoever?
TOTAL= ________ (total should equal 28)
Pain Diagrams
FRONT
BACK
SIDE
Continuous Headache
• Is it really?
• Is it severe?
• Is it Migraine?
– If not……………………
– What?
• Is it a headache?
New Daily Persistent Headache
• Is it really new?
– Prior history of headache
– How should we ask?
• Leading the witness
• Following the leads
• Does it have to be continuous?
• Is it a primary headache disorder?
THE 50% RULE?
If in many of your patient’s with
NDPH you find SOMETHING
Then: Is NDPH an Other Primary
Headache?
Comorbidities and Predictive Factors in NDPH
Preceding Event
Vaccine
3%
Surgery
3%
None
22%
n = 36
78% HAD SOMETHING
Rheumatologic
8%
Infection
39%
Trauma
25%
Hindiyeh, N et al, Presented at the 56th Annual Scientific
Meeting of the AHS, 27JUN2014
Side Locked Headache
• Location
– Surface area
– Radiation
– Associations
• Duration
– TAC?
• Interictal headache
– HC w &w/o features
Side Locked Headache
• Severity
• Examination findings
– Hyperesthesia
– Hypalgesia
– TMD/TMJ
– Cervicogenic
• Primary
• Secondary
Side Locked Headache
• Cervicogenic (11.2.1)
– Primary
– Secondary
OR
• Is it 11.2.3 (Headache Attributed to
Craniocervical Dystonia
– Inclinometry
Focal Headache
• Without migraine features
– Nummular headache
– Neuralgiform pain
• With migraine features
– Peripheral v central sensitization
– Phantom head pain
Stress and Distress
• Diseases and drugs
– If nothing works
– Then do we know what we are treating?
• Don’t ask….Don’t tell
• Testing for distress
– P_SD?
– Aphysiology
• What to do when there is no on else to care!
What To Do?
• Examine the history
– I have notes – quality?
– If available look at headache calendars (some
actually keep them on their own)
• Examine the treatments
– Drugs that did work
• What if daily triptans render them headache free?
– Drugs that didn’t work
• Dosing, etc.
– Drugs that might work
– Drugs that don’t work !!!
What Do I Do?- Biopsychosocial Models
• Examine the patient
– The neurologic examination is GROSS
– Test, touch and move
• The sensory examination of the head
– Named nerves
» GON/LON, Supraauricular/Superficial Temporal/SON
– Inject if necessary
• TM Joints?
• Cervical ROM
– Inclinometry?
Biopsychosocial Models
Use validated instruments - Adapt as necessary
• Lot’s of neurologic stuff: Neurobehavioral
Symptom Index (NSI)
• PTSD = Post Traumatic Checklist – Civilian
(PCL-C)
• Mood/Behavioral
– Patient Catastrophizing Scale (PSC)
– BAI, BDI
Current treatments
• Neurotoxins
• Medications
– Episodic migraine prevention for chronic
migraine?
• Procedures
– The worst of the worst?
• Multidisciplinary
• Neil Raskin
– “You are intractable”
The Goal
• Validate the Model
– Is the patient credible?
• The best evidence still exists for N= 1
• 1 is the loneliest #
– Are there confounds?
• Medical
– ?MOH
• Behavioral
– “Intractability”
– Is the HEADACHE credible?*******************
• AND THEN 
What Do I Do?
Biopsychosocial Models
• Examine the history
– Phenomenology: What would it be if it could be?
• Examine the patient
– Include the mind: What would it do if it could do?
• Examine myself
– “we were people before we were clinicians”
• Defaults
• Heuristics
What Do I Do?
Biopsychosocial Models
• Examine the patient – Psycho Social
– I was not trained to look into people’s souls
• Use validated instruments
• Adapt as necessary
What Do I Do?
Biopsychosocial Models
• Examine myself
– “we were people before we were clinicians”
• Heuristics
• Defaults
– MOH
– Psychology and the soul
Conclusions – What should we ALL do?
• Chronic migraine is the same no matter where
I see it
• Manage people
– Not drugs
• Include your biases - Intractability
– Cathexis
• Treat what you think/know
– Counter – transference
• Not what you feel
Conclusions
• The refractory headache patient is:
– Challenging
– Exciting
– Frustrating
• And
– Satisfying
Thank you for your attention
President and CEO, The Carolina Headache Foundation, Chapel Hill , NC
Director, Carolina Headache Institute , Chapel Hill, NC
Professor, University of North Carolina
Contractor, Defense and Veteran Brain Injury Center
TNS 2015