Treatment in chronic migraine: choice of reabilitation strategies

Abstract

Migraine is a disabling neurologic condition with a spontaneous clinical evolution into a chronic form. Migraine progression from an episodic into a chronic form is realized through a period of time involving several months or years, during which an increase attack frequency occurs. .According to the International Classification of Headache Disorders (ICHD-3) chronic migraine is a type of primary headache occurring on 15 or more days per month for more than 3 months, in which more than 8 days per month headache meet criteria for migraine with or without aura or respond to specific migraine treatment. The prevalence of chronic migraine is estimated between 13% of general population. Persons with chronic migraine are more likely to suffer from severe disability; chronic migraine has an important socio-economic impact. Diagnostic approach in chronic migraine includes exclusion of a secondary headache disorder and confirmation of a primary episodic headache. When a patient is found to overuse pain medication, diagnosis of both chronic migraine and MOH should be considered. Treating episodic migraine early and managing attack frequency using preventive medication and behavioural interventions will be benefic in reducing the risk of chronicisation. Lifestyle changes are important for avoiding triggers for migraine attacks; treatment of comorbidities is equally important because these conditions exacerbate patient’s tendency to have headaches. The initial relief step for drug abusers always relies in drug withdrawal. For migraine attacks treatment begins with non-pharmacologic interventions (staying in a quiet, dark room, pressure on painful areas, applying cold compresses ), simple OTC analgetics (NSAIDs, paracetamol, aspirin, acetaminophen). If these are not effective, triptans are the drugs of choice. Preventive treatment is always recommended in patients with chronic migraine because the high frequency of headache attacks. Treatment should be started with topiramate, because the drug has the highest level of evidence in treating CM; Onabotulinumtoxin A reduced the number headache days, headache severity, headache-related disability and improved functioning and quality of life. Additionally, complementary and alternative medicine treatments are available in CM prophylaxis, such as biobehavioral techniques (relaxation training, thermal biofeedback, electromyography feedback and cognitive-behavioral therapy). Invasive and non-invasive neurostimulation techniques have been studied in the treatment and prevention of various types of headaches, including chronic migraine. New treatment options for acute attacks and for prevention include calcitonin generelated peptide (CGRP) antagonists and antibodies.