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Abstract
Chronic migraine is a disabling neurological disorder that imposes a considerable burden on individual and socioeconomic outcomes. Chronic migraine is defined as headaches occurring on at least 15 days per month with at least eight of these fulfilling the criteria for migraine. Chronic migraine typically evolves from episodic migraine as a result of increasing attack frequency and/or several other risk factors that have been implicated with migraine chronification. Despite this evolution, chronic migraine likely develops into its own distinct clinical entity, with unique features and pathophysiology separating it from episodic migraine. Furthermore, chronic migraine is characterized with higher disability and incidence of comorbidities in comparison to episodic migraine. While existing migraine studies primarily focus on episodic migraine, less is known about chronic migraine pathophysiology. Mounting evidence on aberrant alterations suggest that pronounced functional and structural brain changes, central sensitization and neuroinflammation may underlie chronic migraine mechanisms. Current treatment options for chronic migraine include risk factor modification, acute and prophylactic therapies, evidence-based treatments such as onabotulinumtoxinA, topiramate and newly approved calcitonin gene-related peptide or receptor targeted monoclonal antibodies. Unfortunately, treatments are still predominantly ineffective in aborting migraine attacks and decreasing intensity and frequency, and poor adherence and compliance with preventative medications remains a significant challenge. Novel emerging chronic migraine treatments such as neuromodulation offer promising therapeutic approaches that warrant further investigation. The aim of this narrative review is to provide an update of current knowledge and perspectives regarding chronic migraine background, pathophysiology, current and emerging treatment options with the intention of facilitating future research into this debilitating and largely indeterminant disorder.
Highlights
Chronic migraine is a debilitative neurological disorder that impacts on average 1.4–2.2% of the global population and imposes a significant individual and socioeconomic burden [1]
While chronic migraine and episodic migraine are often conceptualized as disorders of the same spectrum, some researchers and clinicians suggest that chronic migraine develops into its own distinct clinical entity with an episodic migraine predisposition, accounting for ∼8% of the total migraine population [7,8,9,10]
It has been reported that chronic migraineurs display reduced pain modulatory ability during the interictal period [107] and whilst the function of brainstem pain modulating circuits has not been directly explored in chronic migraine, recent episodic migraine studies reported altered resting state functional magnetic resonance imaging connectivity within the periaqueductal gray matter (PAG)-rostral ventromedial medulla (RVM)-SpV pathway during the interictal period [108]
Summary
Chronic migraine is a debilitative neurological disorder that impacts on average 1.4–2.2% of the global population and imposes a significant individual and socioeconomic burden [1]. Whilst some authors suggest that pathophysiological mechanisms involved in migraine are present in MOH [35], emerging evidence has begun to provide insights into potential underlying mechanisms of medication overuse in headache chronification [41,42,43].
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