Everything is loud, bright, and your head is pulsating with pain. You might even feel as though a vice grip is clenching your skull. Migraine sufferers know what it's like to have an entire day sidelined because of an irresistible urge to hide in a cool, dark room.
But one migraine is bad enough. Imagine having several every month. Chronic migraines differ from typical migraines in part by how often they happen but also because most chronic migraine sufferers have several non-migraine headaches the rest of the month.
“Very often I’ll ask a patient, how many migraines do you have a month? And they’ll say, ‘oh, maybe two a week,'” says Robert Cowan, MD, professor of neurology and chief of the division of headache medicine at Stanford University. But when he asks if they’re headache-free the other 22 days of the month, they’re quick to correct themselves. “They say, ‘No, no, I have my regular headaches, those are every day—but I only seem to have migraines about twice a week.”
Chronic migraine is defined as “a patient that has headache more than 15 days per month, of which eight or more have migrainous features,” Dr. Cowan explains. That’s based on the International Classification of Headache Disorders.
What are chronic migraine symptoms?
For migraine sufferers, their migraines often feature "a mostly one-sided headache with either nausea or a combination of light and sound sensitivity, worsened by exercise, and is moderate to severe," Dr. Cowan explains.
Per the American Migraine Foundation, symptoms for a typical migraine include:
- Moderate to severe pain on one side of the head, although it sometimes happens on both sides
- Throbbing or pulsing pain
- Sensitivity to light
- Sensitivity to sound
- Sensitivity to smell
- Sensitivity to touch
- Nausea and vomiting
- Pain that gets worse with exercise
But, as mentioned, chronic migraines also feature general “headache” days. Headaches come in different forms, according to the Cleveland Clinic, but generally, their symptoms include:
- Consistent, mild-to-moderate pain without throbbing
- Pain on both sides of the head
- Pain that decreases or subsides with over-the-counter treatments
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What causes chronic migraines?
"The main cause is poor parental selection," says Dr. Cowan—that is, your genetics play a big role in how susceptible you'll be to migraines. If a family member has migraines, you're much more likely to experience them.
Migraines are more common in women and tend to start in adolescents, though they can begin at any age. They’re usually the worst in your 30s and begin to lessen as time goes on, according to the Mayo Clinic.
As far as the exact mechanism that causes migraines, it's not entirely clear. It may have to do with changes in the brainstem, or possibly an imbalance in brain chemicals, as the Mayo Clinic explains.
Risk factors that make chronic migraines more likely include obesity, overusing medications, asthma, and poor sleep habits, Dr. Cowan says. A doctor should be looking at health conditions you have, because managing other illnesses may help reduce the frequency of migraines, he explains.
Certain things can trigger migraines. Dr. Cowan says the biggest triggers are a change in sleep, particularly not sleeping well, a change in eating routine or amount, and a big increase in physical activity relative to how active you usually are.
Other triggers include hormonal changes (like those around menstruation), drinking alcohol or caffeine, bright lights, strong smells, and loud sounds, along with certain foods, according to the Mayo Clinic.
But the important thing to understand about triggers is that they build on each other, which can make them hard to identify. For example, a patient who gets a migraine after eating blueberries they may blame the berries, Dr. Cowan explains. But often that person got a poor night's sleep and had a stressful day, and then had blueberry pie. The migraine wasn't triggered by blueberries alone.
Actively managing your migraines may make your triggers less impactful, says Mason Dyess, DO, a general neurology and headache medicine physician at Ochsner Medical Center in New Orleans. “People tend to have more triggers and are more susceptible to their triggers when their migraines are uncontrolled,” he explained. But until you’ve found a regimen that works for you, “if you know something’s going to give you a migraine, avoid it,” he says.
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How are chronic migraines diagnosed?
You’re unlikely to have any imaging done with a migraine. “Ninety-five percent of your diagnosis in headache patients comes from the history,” Dr. Cowan explains. The more information you have about your experience with headache and migraine, the better your doctor will be able to diagnose you. Try making a note each day you have a headache or migraine before your appointment.
That’s important, explains the American Migraine Foundation, because chronic migraine is diagnosed based on the number of headache days you have, not on how disabling the condition may be.
Your doctor may also do a physical exam to check your neck range of motion and touch the back of the head and around your temples and eyes to check on certain nerves. "That can tell me a lot about how to treat the patient," Dr. Cowan says.
If you're having frequent headaches, your doctor will want to rule out other potential causes, such as an underlying health condition or a different type of headache, notes the American Migraine Foundation.
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How do you get rid of chronic migraines?
Treatments for chronic migraines can be broken into two categories: preventive medications that help reduce the number of migraines every month and acute medications for when you actively sense a migraine coming on.
"Most patients take both if they have chronic migraine," Dr. Dyess says.
But it's important to know when to take them. "The acute medications are supposed to be employed at the very first sign of migraine," Dr. Dyess explains. That means as soon as you feel any pain. Acute medicines include over-the-counter medications like ibuprofen or aspirin and headache-specific medicines called triptans, such as sumatriptan and rizatriptan.
Preventive medications include oral medications, like beta blockers, antidepressants, and seizure medications. They might also include injectables, like Botox or calcitonin gene-related peptide (CGRP) inhibitors.
There are also newer CGRP blockers in pill form, which are approved as both acute and preventive medicine. This category includes Nurtec (rimegepant) and Ubrelvy (ubrogepant). "We probably get the most questions about them right now," says Dr. Dyess, because they've been popularized by several celebrities. "Those work to fundamentally help the inflammatory pathway, to stop the inflammation that leads up to a migraine."
You may also take other medications that help with migraine side effects, such as Zofran (ondansetron) for nausea.
The important point is this: if you're struggling with migraines, talk to your doctor—especially if your headaches or migraines have been increasing. "I'm more concerned about a patient who's gone from two headache days a month to six or eight headache days a month. That person is still going to be defined as episodic, but that's a patient that's in trouble or headed for trouble," says Dr. Cowan. "That patient's on their way to being disabled by their headaches if you don't intervene."
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