Complete Relief from Migraine

Types of Migraine

Chronic Migraine

Chronic migraine (CM) best characterizes those patients with a history of migraine who experience headache more than half the time. The following criteria for CM have been put forth by the International Headache Society:

  • Headache, of either tension-type and/or migraine quality, occurs on ≥15 days per month for at least 3 months.
  • On ≥8 days per month the patient experiences the pain and associated symptoms of migraine without aura and/or treats and experiences relief before the expected development of symptoms.
  • No medication overuse.


Refractory Migraine (RM)

Despite advances in headache therapies, there remains a group of sufferers with refractory (intractable, treatment - resistant) headache who fail to respond to or cannot tolerate current evidence – based treatments. Although the concept of Refractory Headache (RH) has a long history, there have been few attempts to formalize an operational definition. The International Classification of Headache Disorders, Second Edition (ICHD - 2) does not include a definition for RH. Certain migraines are labelled as refractory, but the entity lacks a well – accepted operational definition. Efforts are now been made to reach a consensus on refractory migraine which includes – persistent and disabling migraine despite several adequate management trials.

The RM patients must meet the ICHD – 2 criteria for migraine or chronic migraine respectively.

  • Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy.
  • The patient fails 3-4 adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta – blockers, anticonvulsants, tricylics and calcium channel blockers. Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulations and either nonsteroidal anti – inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated. An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least 2 months at optimal or maximum – tolerated dose, unless terminated early due to adverse effects.
  • Modifiers for the presence or absence of medication overuse, and with or without significant disability.

  • Reference:
    1. Morris L. Refractory headache: classification and nomenclature. Headache 2008; 48:783-90
    2. Schulman EA, Lake AE 3rd, Goadsby PJ, Peterlin BL, Siegel SE, Markley HG, Lipton RB, Defining refractory migraine and refractory chronic migraine: proposed criteria from the refractory Headache Special Interest Section of the American Headache Society. Headache 2008; 48(6):778 – 82.

Rebound/Medication Overuse Migraine

  • Analgesic agents are prescription or over-the-counter medications used to control pain including migraine and other types of headaches. When used on a daily or near daily basis, these analgesics can perpetuate the headache process. They may decrease the intensity of the pain for a few hours; however, they appear to feed into the pain system in such a way that chronic headaches may result.
  • The medication overuse headache (MOH) may feel like a dull, tension-type headache or may be a more severe migraine-like headache. Other medication taken to prevent or treat the headaches may not be effective while analgesics are being overused. MOH can occur with most analgesics but are more likely with products containing caffeine or butalbital.
  • Unless the overused analgesics are completely discontinued, the chronic headache is likely to continue unabated. Usually when analgesics are discontinued the headache may get worse for several days and the sufferer may experience nausea or vomiting. However, after a period of three to five days, sometimes longer, these symptoms begin to improve. Preventive medication will be needed to reduce the need for analgesics. For those patients willing to persevere, the headaches will gradually improve as response to more appropriate medication occurs. Most patients are able to stop the use of analgesics at home under physician supervision, but some find it difficult and may require hospitalization. If you have overused analgesics, you are at high risk of relapsing and using too many analgesics again in the future.
  • Medications such as ergots, triptans, opioids and barbiturates should not be used more than ten days per month. Simple analgesics should not be used for more than 15 days per month. By observing these limits patients will reduce the risk of MOH.


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