Page 143 - The clinical aspects and management of chronic migraine Judith Anne Pijpers

Conclusion
Chronicmigraineisadisabling,highfrequentvariantofmigraine,inwhichpatients experience headache on at least 15 days per month, of which at least 8 migraine days. The definition of chronic migraine is ambiguous, due to the heterogeneity within this subgroup. A revised classification discerning chronic migraine with and without medication overuse, mainly based on number of migraine days would be beneficial. Medication overuse is an important independent risk factor for migraine chronification, as well as anxiety and depression. These factors are implied to promote central sensitisation, a process of enhanced pain facilitation, which is a key mechanism in chronification pathophysiology. A clinical marker of central sensitisation is cutaneous allodynia, the perception of pain to a non-painful stimulus to the skin. Cutaneous allodynia is not only a clinical risk factor for migraine chronification, but seems also predictive for treatment response. Withdrawal therapy is the first choice of treatment in case of chronic migraine with medication overuse. It is a cost-effective therapy, associated with meaningful improvement. Intensive support by a headache nurse during withdrawal therapy is important to increase success rates. Botulinum toxin A has no additional benefit over withdrawal therapy alone, and should not be included in withdrawal therapy. Also for other new developed preventatives (antibodies against CGRP or it’s receptor) a comparison with withdrawal therapy alone or the combination of both may be of great importance for the highly disabled patients who suffer from chronic migraine with overuse of acute medication.
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Summary and general discussion
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