Treatment of chronic migraine and medication overuse

According to the 2nd edition of “International Classification of Headache Disorders”, migraine is classified as “chronic” when occurring on 15 or more days per month for more than 3 months”. Most cases of chronic migraine start as migraine without aura, and chronicity may be regarded as a complication of episodic migraine. Usually, if migraine attacks occur on 15 or more days per month, medication overuse is present. But a sample of patients presents both migraine attacks and tension-type headache, so it is difficult for patients to estimate how many attacks fulfil one or another set of criteria. In all cases, the first step of treatment is to stop the intake of drugs used for many years and to start an intravenous therapy and a preventive treatment program. Another preliminary step is the identification of comorbid psychiatric conditions and exacerbating factors. If large amounts of butalbital-containing analgesic combinations are used, phenobarbital should be administered in order to prevent withdrawal symptoms. Similarly, benzodiazepines and opiates must be gradually reduced. In some cases in-patient treatment is required.