Treatment of Chronic Migraine

CURRENT PAIN AND HEADACHE REPORTS

DOI: 10.1007/s11916-010-0159-x

Hans-Christoph Diener, Dagny Holle and David Dodick

Abstract

Chronic migraine is defined in different ways. The most commonly used definition is headache on more than 15 days per month in patients with migraine. Chronic migraine is difficult to treat and requires a multidisciplinary approach. Only two pharmacological treatments have been shown to be effective in placebo-controlled randomized trials: topiramate and local injection of botulinum toxin. Both therapies are effective in patients with chronic migraine with and without medication overuse. Many other substances have been investigated in chronic daily headache. All trials were underpowered and, therefore, recommendations concerning possible efficacy are not possible.

The Evolution of Chronic Migraine: Classification and Nomenclature

Review Article
The Evolution of Chronic Migraine: Classification and Nomenclature
Headache: The Journal of Head and Face PainVolume 49 Issue 8, Pages 1206 - 1213Aubrey Manack, PhD; Catherine Turkel, PharmD, PhD; Stephen Silberstein, MD, FACP
From the Allergan Inc, Irvine, CA, USA (A. Manack and C. Turkel); Neurology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, USA (S. Silberstein).
Correspondence to A. Manack, Allergan Inc., 2525 Dupont Drive, Irvine, CA 92612, USA.
Funding support: This manuscript was sponsored by Allergan, Inc., Irvine, CA, USA.

Conflict of Interest: Drs. Turkel and Manack are employees of Allergan, Inc. Dr. Silberstein has proprietary interest (Speaker/Advisory Board/Grants) in the following commercial health care-related businesses: Abbott, Advanced Bionics, Advanced NeurModulation System, AGA, Allergan, AstraZeneca, Endo, GSK, Lilly, Medtronic, Merck, Ortho-McNeil, Pfizer, Pozen, ProEthic, Valeant, Vernalis.

Copyright Copyright © 2009 American Headache Society
KEYWORDS
chronic migraine • headache • classification • epidemiology • nomenclature • evolution
(Headache 2009;49:1206-1213)

ABSTRACT
After nearly 3 decades of debate, the headache community still lacks globally accepted criteria for chronic migraine. This review summarizes the evolution of chronic migraine nomenclature and criteria. We concluded that although there are discrepancies in the currently proposed criteria, there is a significant amount of overlap with previously used classifications such that they all appear to describe the same subset of highly burdened migraine patients. In order to continue to understand the natural history of chronic migraine, address the unmet medical need, and develop effective therapies, field experts and physicians must have a classification that is well understood and accepted by the broader clinical community. It is our view that of the currently established classifications, the Silberstein and Lipton revised criteria for transformed migraine are the most applicable to daily clinical practice and field research.


--------------------------------------------------------------------------------

Published Online: 28 Apr 2009

Copyright © 2009 American Headache Society


Accepted for publication February 19, 2009.

DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1526-4610.2009.01432.x About DOI

Right-to-left shunt is common in chronic migraine

Right-to-left shunt is common in chronic migraine
SJ Nahas 1 , WB Young 1 , R Terry 2 , A Kim 2 , T Van Dell 2 , AJ Guarino 3 & SD Silberstein 1
1 Thomas Jefferson University Hospital, Department of Neurology and 2 Jefferson Medical College, Philadelphia, PA, and
3 Massachusetts General Hospital, Institute of Health Professions, Boston, MA, USA
Correspondence to Stephanie J Nahas, 111 S. 11th St., Suite 8130, Philadelphia, PA 19107, USA. Tel. + 1-215-955-2031, fax + 1-215-955-1960, e-mail stephanie.nahas@jefferson.edu
Copyright © 2009 International Headache Society

ABSTRACT

Our aim was to determine the prevalence of right-to-left shunt (RtLS) in patients with chronic migraine (CM), and to correlate the presence and grade of RtLS with aura and neurological symptoms, and duration and severity of disease. The prevalence of RtLS in migraine without aura is similar to that of the general population (between 20 and 35%). In migraine with aura, the prevalence is much higher (approximately 50%). The prevalence in CM, with or without aura, is unknown. Consecutive patients between the ages of 18 and 60 years with CM attending a tertiary care specialty headache clinic over an 8-week period were eligible. There were 131 patients in the study. A structured diagnostic interview was performed. Bubble transcranial Doppler with Valsalva manoeuvre determined RtLS presence and grade. Sixty-six percent (86/131) of patients had RtLS, a statistically significantly greater rate than those reported in the general population and in migraine with or without aura (P < 0.001). There was no difference in RtLS rate or grade between those with and those without aura. Specific headache features and the presence of neurological symptoms were similar between those with and those without RtLS. Compared with both the general population and the episodic migraine population (with and without aura), patients with CM, with or without aura, are more likely to have RtLS. The clinical implications of our findings need to be determined.

Received 1 June 2009, accepted 31 July 2009
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1468-2982.2009.02002.x About DOI

Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience

Combined occipital and supraorbital neurostimulation for the treatment of chronic migraine headaches: initial experience
KL Reed 1 , SB Black 2 , CJ Banta II 3 & KR Will 1
1 Department of Anesthesiology, Presbyterian Hospital of Dallas, 2 Medical Director of Neurology, Baylor University Medical Center of Dallas, and 3 Department of Orthopedic Surgery, Presbyterian Hospital of Dallas, Dallas, TX, USA
Correspondence to Kenneth L. Reed MD, 8220 Walnut Hill Lane, Suite 202, Dallas, TX 75231, USA. Tel. + 1-214-345-5656, fax + 1-214-345-5698, e-mail klreed1@swbell.net
Copyright © 2009 International Headache Society


A novel approach to the treatment of chronic migraine headaches based on neurostimulation of both occipital and supraorbital nerves was developed and reduced to clinical practice in a series of patients with headaches unresponsive to currently available therapies. Following positive trials, seven patients with chronic migraine and refractory chronic migraine headaches had permanent combined occipital nerve–supraorbital nerve neurostimulation systems implanted. The relative responses to two stimulation programs were evaluated: one that stimulated only the occipital leads and one that stimulated both the occipital and supraorbital leads together. With follow-up ranging from 1 to 35 months all patients reported a full therapeutic response but only to combined supraorbital–occipital neurostimulation. Occipital nerve stimulation alone provided a markedly inferior and inadequate response. Combined occipital nerve–supraorbital nerve neurostimulation systems may provide effective treatment for patients with chronic migraine and refractory chronic migraine headaches. For patients with chronic migraine headaches the response to combined systems appears to be substantially better than occipital nerve stimulation alone.

Received 24 March 2009, accepted 26 July 2009
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1468-2982.2009.01996.x About DOI