There are many conditions and lifestyle factors that are associated with the development of chronic migraine. These factors might increase the chance of your migraine transforming from episodic to chronic, but the opposite may also be true. For example, depression can play a role in migraine becoming chronic, but having chronic migraine can also be a cause of depression.

Sometimes these factors can be managed to help improve your symptoms and reduce how often you get migraine attacks. However, this can be a complex process, and not all can be improved or prevented, even with the right support and treatment.

These factors include:

• depression and/or anxiety
• other pain conditions such as fibromyalgia
• sleep apnoea
• postural orthostatic tachycardia syndrome (PoTS)
• hypermobility spectrum disorders like Ehlers-Danlos syndrome (EDS)
• mast cell activation syndrome (MCAS)
• obesity
• high stress levels
• overuse of acute migraine medication (see below).

Up to 7 out of 10 people with chronic migraine may experience medication overuse headache. This is a type of daily headache people get when acute (rescue) treatments are taken on too many days of the month.

On average, this looks like:

• paracetamol or non-steroidal anti-inflammatory drugs (e.g. ibuprofen and naproxen) on 15 or more days per month

or

• ergotamine, triptans, opioids (codeine-based medicines) or combination painkillers (e.g. co-codamol) on 10 or more days per month.

When this happens, the medication stops treating pain and starts causing daily headaches. Some acute treatments like atogepant and rimegepant don’t seem to cause medication overuse headache.

When you are living with chronic migraine and experiencing pain regularly, avoiding medication overuse headache can be hard. However, if you are regularly taking painkillers for your migraine and are still experiencing daily headaches, it’s important to speak to your doctor. They can help you try to reduce painkiller use, which might involve trying a new preventive treatment or changing your acute treatment to one less likely to cause medication overuse headache. Managing medication overuse headache is important because if it is left untreated it can lead to worse daily symptoms and preventive treatments being less effective.

There is more information available on our medication overuse headache page.

With the constant nature of chronic migraine, it can be challenging to know when to take acute treatment to avoid medication overuse headache.

If you can identify ‘bad’ days or have clear times when your symptoms get worse, you may be able to prioritise acute medication on these days. Acute treatments work best if taken as soon as the head pain starts. If possible, take your acute treatment at this point.

Over-the-counter painkillers like paracetamol, aspirin or ibuprofen may help your symptoms. If not, your doctor may prescribe a triptan like sumatriptan instead. Avoid painkillers containing opioids, such as codeine, where possible. This is because they can increase nausea, be addictive and increase the chance of you developing medication overuse headache.

Preventive medicines are daily treatments taken to reduce how bad your migraine attacks are and how often they happen. These are often needed in chronic migraine and do not cause medication overuse headache.

There are different preventive treatments available. The treatment you’re offered will depend on a range of factors, including your pattern of migraine attacks, your health history and whether you are or may become pregnant.

Treatment options might include amitriptyline, propranolol, candesartan, topiramate, Calcitonin Gene-Related Peptide monoclonal antibodies (CGRP mAbs), gepants or flunarizine. CGRP mAbs, gepants and flunarizine are not usually available through your doctor but can be prescribed by a headache specialist. Greater Occipital Nerve blocks or Botox may also be offered by a specialist. Availability of these treatments can differ depending on where you live.

Preventive medications are usually started at a low dose, then gradually increased. If you experience side effects, you may need to stay on a low dose for longer and increase the dosage more slowly. The dose is usually increased until either the medication works, the side effects are not tolerated or you reach the maximum dose.

It can take up to 8–12 weeks for a medicine to work fully. Some medicines may work faster than this. Ideally, you should take a preventive for at least three months to assess if it has helped. If you can’t tolerate a medicine due to side effects, don’t carry on taking it, but do let your doctor know so that they can provide advice on how to stop it safely.

If you try one type of preventive medication and it doesn’t improve your symptoms or how often you get attacks, there are other options. If you’ve tried a range of treatments through your doctor and they haven’t worked or are unsuitable for you, your doctor can refer you to a headache specialist. They may have access to a wider range of treatments than your doctor, depending on where you live.

Once you have found an effective preventive treatment, you will usually be advised to continue it for a few months before you consider lowering the dose again.

Although medicine is usually needed to treat chronic migraine symptoms, there are some non-medication options that you may find helpful. These often work best when used alongside medicine.

Non-medication options include:

• supplements – such as riboflavin (B2), magnesium or co-enzyme Q10
• acupuncture
• migraine devices such as Cefaly or gammaCore.

Unfortunately, supplements, acupuncture and migraine devices are not widely available on the NHS and can be expensive.

For some people with chronic migraine, reviewing migraine attack triggers and looking at lifestyle changes from a broader, more holistic viewpoint can be helpful.  Disrupted sleep, high stress levels, poor diet and lack of exercise are all associated with increased inflammation in the body. There is some evidence that this can increase the frequency of (or “trigger”) migraine attacks.

This won’t be the case for everyone and not all triggers can be managed or helped. A lot of people with chronic migraine find that triggers can be hard to identify until their symptoms start to improve. However, even a small change, like trying to maintain regular sleep habits, using relaxation techniques or accessing mental health support, can have a positive effect.

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