Virtual Headache Specialist

Exploring Effective Options for Chronic Migraine Relief; A Roadmap to Respite

Chronic migraine relief and chronic migraine treatment

I see patients stuck in the dark lonely rut of chronic migraine all day every day. Chronic migraine is a miserable headache disorder which causes immense suffering, but with the right combination of adjustments and treatments it is possible to escape. This blog will serve as a roadmap and compass for your escape route. 


Living with chronic migraine can be debilitating, affecting not only your physical health but also your mental well-being. Finding effective relief for chronic migraine is crucial for improving your quality of life, ability to function, and overall happiness. Despite this debilitating condition, there are only 2 treatments that are officially FDA-approved specifically for chronic migraine prevention; Onobotulinumtoxin A (Botox) and Atogepant (Qulipta). However, there are many others treatments used including the CGRP monoclonal antibodies that have been studied and proven effective in chronic migraine. 


In this blog post, we will explore all different options for chronic migraine relief, from traditional medication to holistic approaches and cutting-edge treatments. Let’s delve into the world of chronic migraine treatment and discover the most effective ways to manage this challenging condition.

Chronic migraine relief and chronic migraine treatment


Understanding Chronic Migraines

Chronic migraines transcend the boundaries of mere headache disorders; they embody a multifaceted neurological challenge. Individuals grappling with this condition endure frequent and intense episodes of head pain accompanied by an array of symptoms including, but not limited to, nausea, vomiting, extreme sensitivity to light and sound, and sometimes visual disturbances known as aura. The relentless nature of these symptoms can disrupt daily routines, work commitments, and personal relationships, underscoring the importance of recognizing and addressing chronic migraines with the seriousness they warrant.


Migraines are severe headaches, and the burden of migraine is high. More than 39 million in the US have migraine and more than 1 billion globally. 20% of all women have migraine (1 in 5) and 1 in 16 men have migraine. According to the World Health Organization, migraine now accounts for the #2 leading cause of years lived with disability following low back pain and the #1 cause for women in their prime working years. 


The journey into the dark world of chronic migraines begins with distinguishing them from other types of headache disorders. Chronic migraines are diagnosed when an individual experiences 15 or more headache days per month, with at least 8 of those days meeting criteria for migraines (including nausea, and/or sensitivity to light and sound), for more than 3 months. This definition highlights the persistent and recurrent nature of the condition, setting it apart from episodic migraines, which occurs with a lower migraine frequency (14 or less days per month). 


About 2% of the global population suffers with chronic migraine. Every year, 3% of people with episodic migraine evolve to chronic migraine.


Delving deeper, the pathophysiology of chronic migraines involves complex interactions between the electrical network in the brain and brainstem, its surrounding structures, genetics, environment, and various neurotransmitters such as serotonin. There is variation in how much each of those factors may influence migraines from person to person. Genetics can play a role in the susceptibility to chronic migraines, indicating that a family history of the condition may increase one’s risk. Environmental factors including stress, dietary triggershormonal changes, and sleep disturbances, can exacerbate the frequency and severity of attacks.


This intricate web of causes and contributing factors makes chronic migraines a challenging adversary. However, understanding these aspects is fundamental to crafting effective treatment strategies and ultimately, affording those affected a greater degree of control over their condition. Through a blend of medical knowledge and empathetic care, individuals can navigate the complexities of chronic migraines and embark on a path toward relief and recovery.

The Importance of a Comprehensive Diagnosis

Embarking on the journey to manage chronic migraines begins with securing an accurate diagnosis. This is a critical step, as the symptoms of chronic migraines often intertwine with other headache types and neurological conditions, making differentiation essential. A neurologist or headache specialist plays a pivotal role in this process, leveraging their expertise to navigate the nuanced landscape of headache disorders. I see patients all the time who have been treated as “chronic migraine” for years when in fact it was a different type of headache disorder requiring a different type of treatment (and the reason why they were never improving!). 


The diagnostic odyssey involves more than just using a headache diary; it includes a comprehensive evaluation of your medical history, an assessment of symptoms, full medical and neurological exam, and possibly the implementation of diagnostic tests such as MRI or CT scans. These imaging tests ensure that other potential causes of headaches, such as tumors or vascular abnormalities, are ruled out. Additionally, blood work might be conducted to check for underlying conditions that could be contributing to the migraine episodes.


A detailed understanding of your headache patterns, triggers, and symptoms allows healthcare providers to tailor a treatment strategy that aligns with your specific situation. It’s an approach that underscores the uniqueness of each individual’s experience with chronic migraines, acknowledging that what might be a trigger or symptom in one person could be entirely absent in another. 


Moreover, a comprehensive diagnosis serves as the foundation for developing a personalized treatment plan. It facilitates a targeted approach, allowing for the selection of the most appropriate and effective medication, lifestyle modifications, and alternative therapies. This diagnostic process also enables healthcare providers to recommend preventive strategies, aiming to reduce the frequency and severity of migraine attacks before they occur. There are many migraine comorbidities such as depression and insomnia that must also be evaluated and treated for.


Navigating the complexities of chronic migraine requires a partnership between patients and their healthcare teams. This collaborative effort is essential in crafting a path forward, offering hope and clarity for those seeking relief from the relentless grip of chronic migraines.

Classic Medication Options for Chronic Migraine Relief

Navigating the maze of medication options for chronic migraine relief can feel overwhelming, yet it remains a cornerstone in managing this complex neurological condition. The arsenal of available treatments is diverse, catering to the varied experiences and needs of those living with chronic migraines. Working in close collaboration with a healthcare provider, patients can identify the medication regimen that best mitigates their symptoms while minimizing side effects.


Preventive treatments offer a proactive approach, aiming to decrease the frequency, duration, and severity of migraine episodes. 


There are many options in choosing a preventive medication. Beta-blockers, traditionally used to manage high blood pressure, have been found to the electrical overactivity that precipitates migraines. So they work not by treating blood pressure, but actually targeting the electrical system. There are a few other select blood pressure medications that show benefit in studies as well. 


Select antidepressants and anti-anxiety medications can influence the pathways that contribute to migraine pain, and can be very effective in migraine prevention. Tricyclic antidepressants and SNRIs have the most migraine preventive benefit.


Select anti-seizure medications target the brain’s electrical activity, and can also prevent a migraine’s onset. In fact, there are 2 anti-seizure medicines that are FDA approved for migraine prevention (Topiramate, Divalproex). This highlights the fact that the class of a medicine may be of a completely different category, yet have good evidence for migraine. 


These preventive medications are discussed in greater detail here.


For immediate relief during a migraine attack, acute (abortive) medications become indispensable to stop headache pain. Every migraine patient needs to have an effective abortive. We know that the more migraine goes untreated successfully abortively (and preventively), the more it will progress over time into chronic migraine. There are many options for drug administration including pills, nasal spray, or self-injection.


Triptans, a class of drugs specifically designed for migraine relief, work by constricting blood vessels and blocking electrical pain pathways in the brain. Gepants are a newer type of abortive medicine that also block the electrical pain pathways, without blood vessel constriction. Nonsteroidal anti-inflammatory drugs (NSAIDs), while more commonly associated with general pain relief, can also be effective in alleviating the pain of a migraine attack for some individuals.


Each medication carries its own set of potential benefits and drawbacks, necessitating a personalized approach to treatment. For example, using too much abortive medicines such as triptans and over the counter pain medicines will cause rebound headache and will convert episodic migraine into chronic migraine and continue to worsen it. 


Factors such as the frequency of migraine attacks, accompanying symptoms, and personal medical history play critical roles in determining the most suitable medication strategy. This tailored approach underscores the importance of open, ongoing communication between patients and their healthcare teams. Through such partnerships, the path to mitigating the debilitating impact of chronic migraines becomes clearer, illuminating the way toward enhanced well-being and quality of life.

Botox and CGRP Inhibitors

The landscape of chronic migraine relief has been significantly enriched by the introduction of Botox (OnabotulinumtoxinA, or botulinum toxin), gepants (Qulipta)Calcitonin Gene-Related Peptide (CGRP) inhibitors (Vyepti, Emgality, Ajovy, Aimovig). These treatments represent a paradigm shift, focusing on specific mechanisms that are involved in the onset and persistence of migraine episodes. 


Botox, a neurotoxin, is utilized not just for its cosmetic benefits but for its ability to prevent the transmission of pain signals in the nervous system. Since 2010, Botox was technically the only truly FDA approved treatment of chronic migraine, up until 2023 when Qulipta (Atogepant) became the 2nd FDA approved treatment for chronic migraine. Botox is administered through strategic and specific injections and dosing throughout the head and neck every 3 months.


CGRP inhibitors, a newer class of medications, target the CGRP (calcitonin-genre related peptide) peptide believed to play a critical role in initiating the pain and inflammation associated with migraine headaches. These offer hope to those who have struggled to find relief through other treatments. These include the CGRP monoclonal antibodies and the gepants. By preventing CGRP from binding to its receptors, these inhibitors can thwart the chain reaction that leads to migraine pain, offering a reprieve from the relentless cycle of attacks.


CGRP monoclonal antibodies are available in monthly injectable (Emgality, Ajovy, Aimovig) or quarterly infusion (Vyepti). These are not technically FDA approved for chronic migraine specifically, but they have been shown to be effective for chronic migraine in several different studies. They are commonly used for all frequencies of migraine.


In 2023 Qulipta became the 2nd FDA approved treatment for chronic migraine (Botox was 1st in 2010). Qulipta is a once daily pill, and the only gepant (out of 4) approved for chronic migraine.


The introduction of CGRP inhibitors is especially notable for providing a targeted approach specifically designed for migraine prevention, a testament to the strides being made in understanding the complex biology of migraines. While the effectiveness of these treatments can vary from person to person, they underscore the importance of personalized care in the management of chronic migraines. 

The Role of Neuromodulation in Chronic Migraine Treatment

Neuromodulation therapies represent a groundbreaking frontier in the quest for chronic migraine relief. There are 5 main devices in use. Four of them are FDA cleared for both abortive and preventive migraine treatment (SAVI Dual, Cefaly, GammaCore, Nerivio) and the 5th is FDA cleared as an abortive only (Relivion MG). The way I like to explain these devices to patients is to think of migraine as if your brain is immersed in an electrical storm. These devices help to reboot the system and shut off that storm.


Techniques such as transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) exemplify the innovative approaches to manage this debilitating condition. By precisely targeting the electrical activity within the brain and its nerve pathways (source of migraine), neuromodulation seeks to modulate the intricate neural circuits involved in migraine genesis and propagation. These non-invasive approaches offer the potential for modulating brain activity without the need for pharmaceuticals, presenting a promising avenue for those seeking alternatives to medication. 


SAVI Dual is a single pulse TMS (sTMS) device that helps to stop the electrical wave of cortical spreading depression that occurs early in a migraine attack. It also helps to shut down the overactive brain electrical signals that cause a migraine to flare up.


GammaCore is a VNS device that is FDA cleared for abortive and preventive migraine treatment. Vagus nerve stimulation (VNS) involves the delivery of mild electrical impulses to the vagus nerve, which runs from the brain through the neck and into the abdomen. VNS has been traditionally used in the treatment of certain types of epilepsy and depression. 


Cefaly works by external trigeminal nerve stimulation (eTNS), and is worn across the forehead.


Nerivio is a wireless remote electrical neuromodulation (REN) device that is applied to the upper arm and controlled through a smartphone app. It uses a proprietary stimulation signal that targets specific pain transmitting nerve fibers that disrupts the electrical activity of a migraine centrally from a remote location peripherally (on the arm).


Relivion MG is an external combined occipital and trigeminal neurostimulation system (eCOT-NS) neuromodulation device for acute migraine treatment. It is worn on the head and covers the front and back areas of the head over strategic areas of the trigeminal nerves and occipital nerves.


Patients interested in exploring neuromodulation as a part of their treatment regimen can discuss these options with their neurologists or headache specialists (headache specialists will be most familiar with them. As the landscape of migraine treatment continues to evolve, neuromodulation stands as a testament to the relentless pursuit of innovative solutions aimed at restoring quality of life for those affected by chronic migraines.

What is a Holistic Approach to Chronic Migraines? Beyond Medication: Lifestyle Adjustments and Alternative Therapies.

A holistic approach to chronic migraines recognizes the individual as a whole, intertwining physical, emotional, and lifestyle elements into a cohesive treatment strategy. This makes great sense given the many comorbidities that often accompany migraine. A holistic approach extends beyond the realm of traditional medication, exploring how daily habits, environmental factors, and stress management techniques can significantly influence the frequency and intensity of migraine episodes. 


Holistic remedies prioritize non-pharmacological interventions that aim to enhance the body’s inherent ability to heal and maintain balance, thereby reducing reliance on medication and minimizing potential side effects.


At the core of a holistic strategy are lifestyle adjustments. Simple, yet profound changes such as establishing a consistent sleep routine, engaging in regular physical activity, and adopting a balanced diet rich in magnesium and omega-3 fatty acids can create a conducive environment for migraine management. Identifying and avoiding specific dietary triggers is equally crucial, as certain foods and beverages have been known to precipitate migraine attacks in some individuals.


Stress, an unavoidable trigger for many, necessitates the integration of effective stress management techniques into daily life. Stress is one of the biggest migraine triggers. Practices such as yoga, meditation, and deep-breathing exercises not only foster relaxation but also improve the body’s resilience to stress, potentially diminishing the occurrence of migraines. Cognitive behavioral therapy (CBT) further complements this approach by equipping individuals with strategies to alter negative thought patterns that may exacerbate migraine pain.


Exploring alternative therapies offers additional avenues for relief. Acupuncture, for instance, has garnered attention for its potential to alleviate migraine symptoms through the strategic placement of needles, promoting the flow of energy and reducing inflammation. Similarly, biofeedback teaches individuals to control physiological processes that are typically involuntary, such as muscle tension and blood pressure, empowering them to mitigate migraine episodes actively.


In embracing a holistic approach to chronic migraines, the aim is to foster a synergy between mind, body, and environment, crafting a personalized and multifaceted treatment plan that resonates with the individual’s unique needs.

What is the Most Effective Treatment for Chronic Migraine? Developing a Personalized Treatment Plan.

Everyone’s migraine circuitry may vary in which pathways their migraines are most dependent on. This fact underlies the reason why one treatment works great for some people but not for others. Not all migraine is the same. So the quick answer is that there is not one single most effective treatment, because people can have different responses to different treatments. However, going after the treatments with the best evidence behind them is a good place to start. Then working down the line of options is the way I approach treating chronic migraine.


Iidentifying the most effective treatment for someone with chronic migraine necessitates a deeply personalized and adaptable strategy. This approach recognizes that the interplay of genetic predisposition, lifestyle factors, and individual health history shapes the manifestation of migraines uniquely for each person. The journey toward optimal relief involves a close partnership between patients and their doctors, embarking on an often frustrating process of trial, observation, and adjustment. 


BUT NEVER GIVE UP!! The goal is to prevent a life of chronic migraine as I wrote about with my 67 year old patient Frank.


A tailored treatment plan for chronic migraine incorporates a blend of preventive medications to reduce the occurrence of migraines, alongside acute treatments to alleviate headache attacks when they arise. However, the foundation of effective management extends beyond pharmacological interventions. Incorporating lifestyle modifications, such as dietary adjustments, regular physical activity, and stress-reduction techniques, plays a critical role in mitigating triggers and enhancing resilience against migraine attacks.


Moreover, exploring alternative therapies and emerging treatments, like neuromodulation or CGRP inhibitors, can offer additional layers of relief. These options underscore the importance of staying informed about the latest advances in migraine research and being open to integrating novel approaches into one’s treatment regimen.

Navigating Insurance and Access to Care

The pathway to securing comprehensive care and treatment for chronic migraines often intersects with the complex landscape of insurance policies and healthcare access. Honestly, fighting insurance companies with appeal letters for denial of necessary treatments every day all day is the absolute worst part of my job and a leading driver for physician burn out. If insurance companies would simply allow doctors to practice medicine in the way they feel would be best for their patients, life would be much better for everyone.


Understanding the intricacies of your insurance plan is important, as coverage for various treatments, consultations, and potentially life-altering therapies can vary widely. Each patient’s journey toward relief is unique, and navigating the maze of insurance benefits, limitations, and requirements can add an additional layer of challenge and headache to managing chronic migraine. When picking out an insurance plan, there are some important points to look for in a plan to ensure migraine treatment options will be wider.


Initiating a dialogue with your insurance provider is a good first step. Inquire about the specifics of coverage related to chronic migraine treatment, including but not limited to, consultations with specialists, preventive medications, acute treatments, and innovative therapies such as neuromodulation or CGRP inhibitors. Understanding your plan’s prerequisites for coverage, such as referrals to specialists or pre-authorization for certain medications or treatments, is essential to streamline your path to care.


For individuals encountering obstacles with insurance coverage or those without insurance, exploring alternative avenues for accessing care is key. Many healthcare providers and treatment centers offer sliding scale fees based on income or payment plans to ease the financial burden. Additionally, patient assistance programs provided by pharmaceutical companies can offer reduced-cost or free medication to those who qualify.


Leveraging telehealth services can also provide a cost-effective and convenient option for consultations with migraine specialists, especially in areas where such specialists are scarce. This modality of care has expanded access for many patients, offering expert guidance without the need for travel. There are only around 700 certified headache specialists in the entire US, so this has become a crucial avenue to many out of state patients without access to a nearby headache specialist.


In the journey toward chronic migraine relief, being proactive, informed, and persistent in navigating insurance and healthcare access can significantly impact your ability to receive timely and effective treatment. Engaging in advocacy for oneself, armed with knowledge and supported by healthcare professionals, can help demystify this process, bringing you closer to the relief you seek.

The Importance of Support Systems in Managing Chronic Migraines

Navigating the complexities of chronic migraines can often feel like a solitary journey, but the power of a robust support system cannot be underestimated. Migraine affects not only patients, but their families and friends as well. Cultivating connections with family, friends, and healthcare professionals provides not only a network of understanding and empathy but also a foundation for practical support and shared knowledge. 


Engaging with support groups and online forums introduces a community perspective, offering insights and experiences from others who are similarly navigating the challenges of chronic migraine management. These platforms can become invaluable resources, presenting new coping strategies, and fostering a sense of belonging among individuals who truly comprehend the intricacies of living with chronic migraines.


Additionally, professional counseling services can play a critical role in addressing the emotional and psychological toll of chronic migraines, as these are common comorbidites. The guidance of therapists or counselors who specialize in chronic pain or chronic illness can equip individuals with the tools needed to manage not just the physical symptoms of migraines but the mental health challenges that often accompany them. This holistic approach to support underscores the interconnectedness of physical health, mental well-being, and social connectivity in the management of chronic migraines.


As the journey with chronic migraines unfolds, remember that seeking and accepting support is a sign of strength. It reflects an understanding that managing this condition extends beyond medical treatment alone. The engagement with a supportive network—be it composed of loved ones, peers, or professionals—serves as a crucial pillar in constructing a comprehensive strategy for navigating the challenges of chronic migraines, ensuring no one has to face this path alone.

Looking Forward: Advances in Chronic Migraine Research

The realm of chronic migraine research is continually evolving, with scientists working to unravel the complexities of this condition. This dedication to discovery promises to transform the landscape of treatment options and offers hope to those who endure the daily struggles associated with chronic migraines. 


Breakthroughs in understanding the genetic components of migraines, alongside the development of novel drug therapies, signal a new era of personalized medicine and innovative approaches in migraine management. New medication classes targeting new migraine pathways is key since many people still have migraines that don’t respond well to available options. PACAP inhibitors offer one of the newest migraine pathway targets and studies are ongoing now.


The expansion of clinical trials provides a crucial pathway for patients to access new treatments that are on the forefront of migraine science. These studies not only offer a glimpse into potential future therapies but also empower patients to play an active role in the quest for solutions.


The horizon is bright with the potential for groundbreaking therapies that more precisely target the underlying causes of chronic migraines, aiming to reduce their impact significantly. Staying abreast of these developments and engaging with the scientific community through participation in research can open doors to innovative treatments and contribute to the broader understanding of chronic migraines. 


As we look forward, the promise of these advances fuels optimism for a future where chronic migraine relief is within closer reach, marking a hopeful path forward for millions seeking respite.







Last Updated on June 22, 2024 by Dr. Eric Baron

Dr. Eric Baron

Dr. Eric P. Baron is a staff ABPN (American Board of Psychiatry and Neurology) Board Certified Neurologist and a UCNS (United Council for Neurologic Subspecialties) Diplomat Board Certified in Headache Medicine at Cleveland Clinic Neurological Institute, Center for Neurological Restoration – Headache and Chronic Pain Medicine, in Cleveland, Ohio. He completed his Neurology Residency in 2009 at Cleveland Clinic, where he also served as Chief Neurology Resident. He then completed a Headache Medicine Fellowship in 2010, also at Cleveland Clinic, and has remained on as staff. He is also a Clinical Assistant Professor of Neurology at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He has been repeatedly recognized as a “Top Doctor” as voted for by his peers in Cleveland Magazine, and has been repeatedly named one of "America's Top Physicians". He is an author of the popular neurology board review book, Comprehensive Review in Clinical Neurology: A Multiple Choice Question Book for the Wards and Boards, 1st and 2nd editions, and has authored many publications across a broad range of migraine and headache related topics. To help patients and health care providers who do not have easy access to a headache specialist referral due to the shortage in the US and globally, he created and manages the Virtual Headache Specialist migraine, headache, and facial pain educational content, blog, and personalized headache and facial pain symptom checker tool. You can follow his neurology, headache, and migraine updates on Twitter @Neuralgroover.