Chronic Migraine

Chronic migraine as a disease was initially recognized in patients with a large burden of disability from frequent headaches and a history of prior migraines. Over time, this observation was operationalized into multiple diagnostic criteria with requirements for frequent headache days, typically 15 or more, which, on at least 8 days in a month, have the features of migraine headache. Chronic migraine affects 1–2% of the general population, and about 8% of patients with migraine. Understanding disease mechanisms still remains a challenge. Inflammation and central sensitization play significant role in the evolutive mechanisms of chronic migraine. Treatment of this condition should primarily focus on the prevention. The currently available evidence-based prophylactic treatment options are topiramate, valproic acid, onabotulinumtoxin A and recently developed promising anti-CGRP monoclonal antibodies. Chronic migraine research is a dynamic and rapidly advancing area. New developments in this field have the potential to improve the diagnosis, to provide more personalized treatments and to reduce burden of disability.

Minimally Invasive Surgical Treatment of Migraine

Migraine headache (MH) is a very common disorder affecting 10–12% of the world’s adult population. The first line therapy for migraine is usually a combination of conservative treatments but some patients seem to be refractory. For this group of patients, the minimally invasive surgical treatment of migraine might offer a solution. Migraine is usually caused by extracranial sensitive nerve compression due vascular, fascial or muscular structures nearby. The aim of migraine surgery is to relieve such compression at specific trigger points located in the occipital, temporal and frontal regions. From June 2011 until July 2019, we performed MH decompression surgeries in over 269 patients with either frontal, occipital, or temporal migraine trigger sites. In the occipital and temporal areas, nerve decompression was achieved by occipital and superficial temporal artery ligation, respectively. In patients suffering from frontal headache we performed both endoscopic nerve decompression and transpalpebral decompression. Among patient suffering from occipital migraine, 95% of them showed improvement of their condition, with 86% reporting complete relief. As concern temporal migraine, positive outcome was achieved in 83% of the patients (50% complete elimination and 33% partial improvement). In patient suffering from frontal migraine, positive results were observed in 94% of the patients (32% complete elimination, 62% partial improvement). Migraine is a common and debilitating condition that can be treated successfully with minimally invasive surgical procedure especially for those patients non-responding to medical therapies.

Medication Overuse Headache

Medication overuse headache (MOH) is defined in the latest ICHD-3 criteria as a secondary headache caused by worsening of a pre-existing headache (usually a primary headache) owing to overuse of one or more attack-aborting or pain-relieving medications. MOH can be debilitating and results from biochemical and functional brain changes induced by certain medications taken too frequently. Various risk factors some modifiable, other non-modifiable (Multiple Gene Polymorphisms) have been hypothesised in MOH. Psychiatric co-morbidities in MOH are noticeably (anxiety and depression) found to be co morbid disorders by more than chance. This has to be managed effectively along with treatment strategies for MOH for efficacious response to withdrawal treatment. Ample literature and clinical evidence shown in prospective trials, that withdrawal therapy is the best treatment for MOH. The mainstay of MOH treatment is not only to detoxify the patients and to stop the chronic headache but also, most likely, to improve responsiveness to acute or prophylactic drugs. Studies advocating prophylactic treatment with good response to mainly topiramate and OnabotulinumtoxinA do exist, less prominent for prednisolone, however, not recommended for every patient. Management may be complex and must be done via MDT approach with involvement of specialists when needed along with incorporating adequate treatment of acute withdrawal symptoms, educational and behavioural programs to ensure patient understanding of the condition and compliance. There are arguments on either sides of inpatient and outpatient withdrawal for MOH patients dependent heavily on the individual circumstances i.e. patient’s motivation, the duration of the overuse, the type of overused drugs, possible previous history of detoxification failures and co morbidities. Treatment trials are still required to determine for clinicians the best evidence-based approach for helping these patients break their headache cycle.

Chronic Migraine in Adolescence

Chronic migraine (CM) is a clinically and epidemiologically important disease that generates considerable impairment to those affected by it, since there is evidence of higher incidence of depression, anxiety, and chronic pain in patients with this condition. It is characterized by the occurrence of headache for at least 8 migraine days in a month and at least 15 headache days in the same month. Despite the similarity in CM presented in adults, when in adolescents it has some particularities. Thus, the aim of this chapter was to conduct a literature review, using the databases: PubMed, SciELO, and LILACS, in addition to text books, explaining the definition, epidemiology, risk factors, diagnosis, pathophysiology, treatment, and prevention of CM in adolescent population.

Therapeutic Management: When and What

Migraine is a widespread brain disease that is classified as the second most disabling condition and has the third highest prevalence of all medical conditions. Despite its non-emergent or life-threatening nature, migraine can progress to chronic type, a subform associated with significant morbidity and drug overuse. In the management of migraine, it is important therefore to introduce early prophylactic treatment in order to limit migraine chronification. In this chapter, we will go through all the treatment options, both acute and preventive, pharmaceutical and non-pharmaceutical following this flowchart: 1. Introduction; 2. General principles; 2.1 Symptomatic therapy; 2.2 Prophylactic management; 3. Pharmaceutical therapies; 3.1 Symptomatic; 3.1.1 Disease-specific; 3.1.2 No disease-specific; 3.2 Prophylactic; 3.2.1 Disease-specific; 3.2.2 No disease-specific; 3.3 Non-Pharmaceutical therapies; 3.4 Neuromodulation; 3.4.1 Invasive; 3.4.5 Non-invasive; 3.5 Nutrient (nutraceuticals); 3.6 Dietary interventions; 3.7 Acupuncture; 3.8 Physical therapy; 4. Cognitive behavioral therapies; 5. Patient centricity and patient education.

Recent Advances in Migraine Therapy

Migraine characterized by recurrent headache episodes presents with aura or without. Various treatment modalities ranging from 5-HT1B/1D agonists, nonsteroidal anti-inflammatory drugs (NSAIDs), to steroids are available for acute treatment of migraine. Prophylaxis for chronic cases usually encompasses β blockers, calcium channel blockers, and antiepileptics. Many nutraceutical preparations are helpful in migraine, including riboflavin and vitamin B12. This review focuses on the newer agents available for treatment of migraine with some insights into their clinical trials.