Managing Chronic Migraine in 2011

Stephen D. Silberstein, MD


April 18, 2011

In This Article

Managing Chronic Migraine in 2011: Background

Chronic daily headache (CDH) is a descriptive term for patients who have a headache occurring more often than not. CDH can be subdivided into chronic migraine (CM), chronic tension-type headache (CTTH), new daily persistent headache, and hemicrania continua. The ICHD-1[1,2] did not classify CM because many Europeans felt that migraine was just an episodic disorder. However, without a CM classification it was difficult to address patients seen in tertiary referral headache centers with disabling headaches that occur more frequently than would be consistent with the "episodic" label. These patients have near-daily headache, with features of both migraine and tension-type headache. It can often be difficult to determine whether a particular headache should be classified as tension-type headache or migraine. Mathew and colleagues described these patients using the term "transformed migraine." The term was used to characterize patients with distinct attacks of migraine whose headaches evolved over the years into a daily or near-daily problem with mixed headache phenotypes. Most of these patients overused acute medication.[2]

Based on clinical observations, Silberstein and Lipton concluded that: 1) ICHD-1 was not comprehensive enough because it failed to classify a large subset of patients with daily headache; 2) daily headache is often transformed migraine and the ICHD-1 criteria for CTTH may not be valid for these patients; and 3) CDH is often associated with medication overuse but may occur without it. Silberstein and Lipton recommended revising the criteria for chronic, frequent primary headache disorders and proposed adding several headache types to the classification system.[3] They defined CDH as all primary headache disorders with daily or near-daily headaches lasting ≥ 4 hours a day untreated. CDH was subdivided into transformed migraine (TM), CTTH, new daily persistent headache, and hemicrania continua (Table 1).[4]

Table 1. Chronic Migraine Criteria

Classification System Criteria
Silberstein Lipton (revised) transformed migraine criteria
  1. Daily or almost daily (> 15 days/month) head pain for > 1 month

  2. Average headache duration of > 4 hours/day (if untreated)

  3. At least 1 of the following:

    1. History of episodic migraine meeting any International Headache Society (IHS) criteria

    2. History of increasing headache frequency with decreasing severity of migrainous features over at least 3 months

    3. Headache at some time meets IHS criteria for migraine other than duration

  4. Does not meet criteria for new daily persistent headache or hemicrania continua

  5. Not attributable to another disorder

ICHD-2 criteria revised in 2006 (ICHD-2R)[5] Appendix 1.5.1 Chronic migraine
  1. Headache on ≥ 15 days per month for ≥ 3 months

  2. Patient has had at least 5 attacks fulfilling criteria for ICHD migraine without aura

  3. On ≥ 8 days per month for ≥ 3 months headache has fulfilled C1 and/or C2 below

    1. Has at least 2 of a-d:

      1. unilateral location

      2. pulsating quality

      3. moderate or severe pain intensity

      4. aggravation by or causing avoidance of routine physical activity

      And at least 1 of a or b:
      1. nausea and/or vomiting

      2. photophobia and phonophobia

    2. Treated and relieved by triptan(s) or ergot before the expected development of migraine above

  4. No medication overuse and not attributed to another causative disorder

The term CM was adopted in place of TM when the ICHD was revised in 2004 (ICHD-2).[1] The original ICHD-2 criteria required ≥ 15 days of ICHD-defined migraine without aura and classified medication-overuse headache separately from CM, making it overly restrictive, not reflective of the majority of patients seen in clinical practice, and difficult to implement. Therefore in 2006, the ICHD-2 criteria for CM were revised.[4] Testing showed that a greater proportion of patients in tertiary headache centers fulfilled these new criteria (Table 1).[5]

Epidemiology of Chronic Migraine

A recent review focused on worldwide population-based prevalence studies that determined rates using either the Silberstein-Lipton criteria or the current ICHD-2 criteria for CM.[6] CM prevalence ranged from 0%-5.1%, with estimates typically in the range of 1.4%-2.2% (varying by region and gender). The target population was well defined by both the Silberstein-Lipton TM definition and the ICHD-2 CM definition. Thus CM represents approximately half of all chronic primary headache cases.


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