Chronic Migraine

What is chronic migraine?

Chronic migraine is a condition where you have frequent or long-lasting episodes of headaches and migraines. With chronic migraine, your symptoms can shift daily (or even hour to hour). That can make it hard to tell where one migraine or headache ends and another begins.

What’s the difference between a headache and a migraine?

IMPORTANT: A migraine isn’t just a bad headache. While the International Classification of Headache Disorders definition of chronic migraine includes both headaches and migraines, they aren’t the same.

Headaches are typically unpleasant and disruptive but aren’t severe enough to affect whether or not you can go about your usual routine or activities. The most common type is tension-type headache (TTH). The main symptom of TTH is pain that affects your head or face, but not your brain.

Migraines affect your brain directly, which is why they’re so severe. It’s common for the symptoms to be severe enough to disrupt your routine and activities. Trying to go about your life as you would under ordinary circumstances can feel unbearable when you have a migraine.

How common is chronic migraine?

Migraines are relatively common, affecting around 12% to 15% of the population worldwide. Chronic migraine is less common, and experts estimate 1% to 2.2% of people worldwide have this condition.

Chronic migraine is more likely to affect women and people assigned female at birth (AFAB). Between 1.7% and 4% of women and people AFAB have chronic migraine, compared to 0.6% to 0.7% of men and people assigned male at birth.

Migraines often start around puberty and usually become less frequent as you age. In women and people AFAB, migraines rarely happen or stop entirely after menopause.

What are the symptoms?

Chronic migraine symptoms are the same as those of episodic migraines. Chronic migraines simply last longer or happen more often. Chronic migraine also involves headaches.

To receive this diagnosis, you must have:

• At least 15 days in a month where you experience a headache or migraine. This must happen for at least three months.
• At least eight days per month where your headaches include migraine symptoms or features. This must happen for at least three months.

Migraines symptoms

As mentioned, migraines aren’t the same as headaches, and they can take different forms. The symptoms you experience from migraine to migraine can also vary. Migraines happen in up to four stages (but not every migraine involves all four):

1. Prodrome: This is a pre-migraine stage. You can often feel subtle differences that hint that a migraine is forthcoming.
2. Aura: These are symptoms that happen as a migraine disrupts different areas of your brain.
3. Headache: This is the pain stage of a migraine.
4. Postdrome: This is when you feel the aftereffects of a migraine. A common way to describe it is like a “migraine hangover.”

With chronic migraine, your symptoms must meet the following criteria:

Migraine without aura (must last between four hours and 72 hours)

A headache phase that meets at least two of the following criteria:

• Pain on one side (left or right) of your head.
• Pain that has a pulsing or pounding feel.
• Pain that’s moderate or severe.
• Pain that worsens with even basic levels of activity (such as walking or using stairs) or makes you avoid activity.

A headache phase that involves at least one of the following:

• Nausea.
• Vomiting.
• Both light sensitivity (photophobia) and sound sensitivity (phonophobia).

Migraine with aura

One or more of the following types of aura symptoms:

• Visual (flashing lights, haze, zig-zag-like areas around the center of your vision or other vision changes).
• Touch (tingling or numbness).
• Speech/language (difficulty speaking or understanding what others say).
• Motor (hemiplegia, which is one-sided weakness or paralysis, affecting your body and/or face).
• Brainstem (loss of coordination, balance issues, vertigo, tinnitus or digestive problems like diarrhea or constipation).
• Retinal (one-sided blindness, either partial or total, or shimmering areas).

At least three of the following criteria:

• At least one aura symptom spreads gradually over five minutes or longer.
• Two or more aura symptoms in succession.
• Each aura symptom lasts between five minutes and one hour.
• At least one aura symptom is one-sided.
• At least one aura symptom with positive symptoms (“good” means the symptoms add an effect; negative symptoms cause you to partly or completely lose the affected ability).
• A headache phase that occurs at the same time or within 60 minutes after an aura.

What causes the condition?

Migraines can be genetic, meaning you’re more likely to have migraines if you have a close biological relative, especially a parent or grandparent, with this condition.

Researchers also suspect several processes could contribute to migraines, including:

• Blood flow changes in your brain because of a widening or narrowing of blood vessels.
• Temporary changes that make it harder for brain cells to conduct electrical signals.
• Brain chemistry changes, including shifts in levels of neurotransmitters like serotonin.
• Incorrect signaling from nerve clusters around your eyes or elsewhere on your head.
• Malfunctions in pain/signal processing centers in different areas of your brain.
• Changes in how your body processes and feels pain because of the effects of chronic pain.

Risk factors

Several factors increase your risk of developing chronic migraine or contribute to making it worse. These include having:

• Obesity.
• Head injuries like concussions.
• Other chronic conditions, especially pain-related conditions like fibromyalgia.
• Mental health conditions like depression or anxiety.
• Sleep disorders, especially sleep apnea.

Migraine transformation

Episodic migraines can sometimes “transform” into chronic migraine. That often happens because of processes that experts still don’t fully understand. There’s evidence that overuse of certain migraine treatments is a possible contributor to this transformation. The term “overuse” here doesn’t automatically refer to a substance use disorder, and it can happen even with medications that aren’t habit-forming.

Because of the risk of transformation, experts strongly recommend against frequent use of certain medications if you have episodic migraine. Medication overuse can also act as a trigger in some cases.

Triggers

Foods, substances, smells, sounds or other environmental factors or circumstances can trigger the start of a migraine, typically within hours or days.

The most common triggers include:

• Stress or anxiety.
• Hormone changes related to menstruation.
• Hunger or dehydration.
• Barometric pressure changes (such as those that happen with weather changes).
• Sleeping too much or not enough.
• Certain scents, fragrances or odors.
• Certain foods or food additives (aged cheeses, red wines, chocolate and aged or preserved meats are some of the most common examples).
• Light (certain types of lighting, or an intense reflection or glare off a reflective surface — even for a fraction of a second — pointed directly at one or both eyes can trigger a migraine).
• Caffeine (especially having too much or less than your usual amount).
• Certain sounds, especially low-frequency sounds like jackhammering or high-frequency sounds like power tools.
• Frequent headache medication use (these are known as medication overuse headaches or “rebound” headaches).

What are the possible complications of chronic migraine?

Complications of migraines are possible but uncommon. They include:

• Status migrainosus (a severe migraine that lasts at least three days).
• Strokes.
• Aura-related seizures.
• Heart attacks (very rare).

How is it diagnosed?

A healthcare provider can diagnose migraines using a combination of approaches. A neurological exam is usually one of the first steps. Your provider will also ask questions about your health history, daily life, routine and activities. Questions usually relate to:

• What the headache feels like, especially your description of the pain, the pain’s location in your head and the pain’s severity.
• If you’ve ever had a migraine before and, if yes, how often they happen.
• If your headaches involve other symptoms, such as light or sound sensitivity.
• If you drink beverages that contain caffeine and, if yes, how much you typically drink.
• If you have any possible migraine triggers (like foods, beverages, fragrances, smells, sounds, etc.).
• How much you typically sleep and your recent sleep habits.
• Your typical stress and anxiety levels and if there’s anything causing stress or anxiety for you now or recently.

What tests will be done to diagnose this condition?

Your provider may recommend certain tests, especially diagnostic imaging scans, such as a computed tomography (CT) scan, to rule out life-threatening conditions like stroke. This is most likely when you have severe neurological symptoms, especially hemiplegia, as this is a key sign of a stroke. In non-emergency situations, you may have a magnetic resonance imaging (MRI) scan instead of or along with a CT scan.

Other tests are also possible, depending on your symptoms. Your healthcare provider is the best person to tell you more about the tests they recommend and why they think these tests are necessary

How is chronic migraine treated, and is there a cure?

Chronic migraine treatments are similar to migraine treatments in general. Medications are the main form of treatment, and there are two main treatment approaches:

• Preventive: This uses medications to prevent migraines or make them less severe or less frequent.
• Rescue: These medications “rescue” you, meaning they shorten migraines and make them less severe.

There are medical procedures that may be an option for chronic migraine. Mental healthcare options can also be a part of treatment.

Preventive medications

Preventive medications are useful for chronic migraine because they make migraines less severe or happen less often. Preventive medications can include:

• Angiotensin II receptor blockers (ARBs), such as candesartan.
• Antiseizure medications (such as valproic acid or topiramate.
• Antidepressants, such as amitriptyline, nortriptyline or venlafaxine.
• Beta-blockers, such as atenolol, metoprolol or propranolol.
• Botulinum toxin (Botox®) injections.
• Calcium channel blockers (CCBs), such as verapamil or flunarizine.
• Monoclonal antibody-based injection treatments, such as erenumab (Aimovig®), fremanezumab (Ajovy®) or galcanezumab (Emgality®).

Rescue medications

These medications shorten a migraine and/or make it less severe. Experts often recommend using these carefully because overuse can lead to or worsen chronic migraine.

Over-the-counter (OTC) and nonsteroidal anti-inflammatory drugs (NSAIDs)

OTC and NSAID medications that can treat migraines include:

• Acetaminophen (sometimes known under the generic name paracetamol, and often better known under the brand names Tylenol® and Panadol®).*
• Aspirin.
• Ibuprofen (also known under the brand names Advil® and Motrin®).
• Naproxen (also known under the brand names Aleve® or Naprosyn®).

*NOTE: Acetaminophen isn’t an NSAID. It’s available over the counter, and experts often include it along with NSAIDs because of its similarities.

Some over-the-counter migraine medications combine NSAIDs with caffeine. It’s a good idea to talk to your provider about whether or not to avoid caffeine-containing products, and to read labels to make sure you’re not taking these products unintentionally.

Triptan medications

These are typically the first-line prescriptions for migraines. These drugs (including the brand names most often used) are:

• Almotriptan (the brand name drug, Axert, is no longer available in the U.S.)
• Eletriptan (Relpax®).
• Frovatriptan (Frova®).
• Naratriptan (Amerge®).
• Rizatriptan (Maxalt®).
• Sumatriptan (Imitrex® or Onzetra®).
• Zolmitriptan (Zomig®).

Your healthcare provider may recommend against using these to treat chronic migraine. Using these too often can cause medication overuse headaches or contribute to transforming episodic migraines into chronic migraine.

Ergotamine

This medication causes blood vessels in your brain to narrow and affects pain signal processing. The brand name form of ergotamine is Ergomar®. Brand name combinations of ergotamine and caffeine include Cafergot® and Migergot®.

Controlled and combination medications

These drugs combine an NSAID and a controlled medication, such as a barbiturate or an opioid painkiller. These can make chronic migraine worse, so they aren’t common in treating this condition.

Medical procedures

There are a few medical procedures that may help with chronic migraine, including:

• Nerve stimulation: The most common nerves for this are the vagus nerve, the occipital nerve (at the back of your head) and the supraorbital nerves (on your forehead).
• Transcranial magnetic stimulation (TMS): This treatment uses a magnetic field to influence your brain’s electrical activity.
• Alternative treatment methods: Other therapies, such as acupuncture (or acupuncture-like methods), may help chronic migraine. While these aren’t as common, they may still help. There are also physicians and other trained and licensed healthcare professionals who offer these treatments.

Mental healthcare

Psychotherapy (the formal term for mental health therapy) may help people with stress and anxiety, which both contribute to migraines. There are many forms of psychotherapy, so you have options to choose from when looking for a method that works for you.

Is chronic migraine preventable, or can I reduce my risk of it happening?

Experts don’t fully understand how or why chronic migraine happens. Because of that, it’s impossible to prevent it with 100% certainty. Some people may be able to reduce their risk of developing chronic migraine, but others with a family history may develop it even if they take precautions.

If you have episodic migraine, the only thing you can do to reduce your risk of developing chronic migraine is to reduce the chance that your medications could contribute to the transformation from episodic migraines to chronic migraine. Your healthcare provider can guide you on using medications wisely and how to reduce the risk of transformation.

What can I expect if I have chronic migraine?

Migraines are very disruptive and make it difficult or nearly impossible to go about your activities as usual. They can disrupt work, household chores and activities, recreational and social plans, and more.

Chronic migraine means you have migraines at least eight times per month for at least three months. Because migraines are disruptive and this condition causes them to happen frequently, experts consider chronic migraine a very disabling condition, meaning it keeps you from doing certain things.

Migraines aren’t usually dangerous, but they greatly disrupt your life. They also increase your risk of life-threatening conditions like stroke and heart attack. Some migraine symptoms can also look like stroke symptoms. Because of that, chronic migraine needs expert monitoring and treatment.

How long does chronic migraine last?

Chronic migraine may not last as long for some people as for others. Some people may have it for months or years, while others may live with it for decades.

Family history, personal circumstances, triggers, treatment effectiveness and other factors can affect how long you have this condition. Your healthcare provider is the best person to tell you what you should expect in your case, and what you can do to reduce how long this condition affects your life.

What’s the outlook for chronic migraine?

Chronic migraine is a condition that can shift and change throughout your lifetime. Between 26% and 70% of chronic migraine cases will transform back into episodic migraine. However, some people will bounce between having episodic migraines and chronic migraine over time.

Migraines tend to become less frequent as you get older. This is especially true for women and people assigned female at birth, as migraines typically happen less often or completely stop after menopause.

How do I take care of myself?

If you have chronic migraine, there are many things you can do to help take care of yourself. These include:

• Keep a migraine journal. This is especially helpful early on but can still be useful no matter how long you’ve had migraines. That’s because it lets you track how your migraines change over time. Migraine journals are especially useful when you’re trying to identify possible triggers.
• Manage your lifestyle. What you eat and your level of activity can affect your migraines. While physical activity can trigger or worsen migraines, finding a way to be active can also improve your symptoms. Reaching and maintaining a weight that’s healthy for you is also important, as having obesity or excess weight can contribute to chronic migraine.
• Don’t be afraid to turn to technology. Apps that log and track migraines are available on most smartphones. Many apps are free, but some have paid options that offer more features. You can also use other kinds of apps, such as weather apps, to warn you of potential triggers like air pollution or changes in barometric pressure.
• Learn your triggers. Once you learn your most common triggers, you can steer clear of these or find ways to minimize how they affect your life. That can help you reduce how often you have migraines, which is a key way to convert chronic migraine back to episodic migraines.
• Talk to others with this condition. There are many ways to learn from others with chronic migraine. There may be support groups that you can attend in your area, and you can also find support groups on social media platforms or through migraine organization websites.

What can’t I eat or drink if I have chronic migraine?

Many foods or beverages can trigger migraines, and triggers can vary from person to person. A migraine journal can help you figure out and avoid your triggers.

Many common trigger foods or beverages involve similar processing methods. These include:

• Fermentation: This is a process used to create wine, beer, cider, distilled spirits and other alcoholic beverages. Other forms of fermentation are key in making cheeses, yogurt and even certain types of bread dough (sourdough is an example).
• Pickling: This process can preserve foods, especially vegetables, meats and other foods. Examples of pickled foods include pickles, sauerkraut, kimchi, eggs, meats and more.
• Curing and aging: Curing is a process that preserves meats so they last longer. Certain curing additives, especially nitrates and nitrites, can commonly trigger migraines. Aging of certain foods, especially meats and cheeses, can also create a trigger effect.

When should I see my healthcare provider, or when should I seek care?

If you have chronic migraine, you should see a healthcare provider (typically a neurologist) regularly for ongoing care. Your provider can recommend an appointment schedule. You should also talk to your provider if you notice symptom changes, especially ones that affect your routine, lifestyle or activities.

When should I go to the ER?

You should go to the ER if you have symptoms that can also happen with dangerous or life-threatening conditions. Examples include:

• Thunderclap headache: This is a headache that starts suddenly and becomes very intense within a few minutes. It’s a possible symptom of bleeding in your brain.
• Extremely severe headache: This refers to what feels like the worst headache you’ve experienced in your life. It’s a possible symptom of an aneurysm, bleeding in your brain or a stroke.
• Hemiplegia: One-sided weakness or paralysis is a key sign of stroke. If you have it, there’s no way to tell if it’s a migraine or a stroke on your own. While hemiplegia from a migraine will eventually go away, you shouldn’t wait to see if it does. That kind of delay can result in permanent brain damage or death if you’re having a stroke.

Is chronic migraine serious?

Chronic migraine isn’t dangerous (except in rare cases), but it is serious. Migraines can be disruptive and make it difficult — or impossible — to go about your usual activities. Having chronic migraine means you have at least eight migraines per month for at least three months. Because this condition involves frequent migraines, which can be extremely disruptive, experts consider it a serious condition.

Does chronic migraine ever go away?

Yes, chronic migraine (and migraines overall) can go away. One way this can happen is with age. Chronic migraine can also transform into episodic migraine, which is often a goal of treating this condition. Episodic migraines are easier to manage and treat and less disruptive because they happen less often.

A note from Cleveland Clinic

A migraine isn’t just a bad headache. Having a migraine often means lying in a dark, quiet room because light and sound cause unbearable pain, nausea and other symptoms. The dark, quiet room doesn’t make symptoms stop. It only keeps them from being even worse. When you have migraines, the symptoms can be frustrating. But sometimes, what’s even more frustrating is trying to explain the experience to those who don’t understand or make assumptions about how it feels.

Fortunately, chronic migraine is often treatable. You can also make small changes to your daily life to reduce the frequency and severity of your migraines. If you combine treatment and manage your migraines, it’s possible to reduce how often you have them and shift your condition to a less severe form. That way, you can focus on your life and not just live from one migraine to the next.