The new appendix criteria for chronic migraine by the IHS6 are
interesting in their inconsistency, as follows:
The official definition of MOH, as revised in the appendix criteria,6 is as follows:
Headache (tension-type or migraine) on 15 or more days per
month for at least 3 months
Headache on 15 or more days per month
Headache occurring in a patient who has had at least 5 IHS-defined
migraine attacks
Headache on 8 or more days in a month, if the headaches
have fulfilled:
IHS criteria for migraine, or
Are treated and relieved by triptan/ergot before the expected
development of symptoms fulfilling IHS migraine criteria
No medication overuse headache (MOH) as defined by IHS 8.2
Regular overuse for more than 3 months of one or more acute/
symptomatic treatment drugs as defined under subforms of 8.2
(of the second edition definitions):
Ergotamine, triptans, opioids, or combination analgesic medications on 10 or more days per month on a regular basis for more than
3 months
Simple analgesics OR any combination of ergotamine, triptans, analgesics, or opiates on 15 or more days per month on a regular basis
for more than 3 months without overuse of any single class alone
Headache that has developed or markedly worsened during
medication overuse
Defining chronic migraine as consisting of both migraine and tension-type headache is problematic and unexpected. In 25 years of treating patients with migraine, this author has never seen a chronic migraine One study shows that 75.2% of chronic migraine patients use
patient who didn’t have MOH. In fact, this phenomenon was first and an average of 3 to 4 tablets of analgesics, mostly simple analgesics,
possibly best known as chronic daily headache.
“isolated or in combination with other substances, such as caffeine.”8
The IHS criteria for chronic migraine and MOH5 consist of
what headache specialists used to call combination headache, in which
patients had migraine, tension-type headache, analgesic rebound, and
vasoconstrictor rebound headache, or 3 of the 4 at the same time.
Some new information is coming to light:
Overuse of symptomatic medication is considered one of the
most important risk factors for migraine progression7:
Opiates—critical dose of exposure is about 8 days per month
(in men more so than women)
Barbiturates—critical dose of exposure is about 5 days a month
(in women more so than men)
Triptans—migraine progression is seen in patients with a high
frequency of migraine at baseline who are taking medications
10 to 14 days per month
The effect of nonsteroidal anti-inflammatory drugs (NSAIDs) varies
with headache frequency, inducing migraine progression in patients
with a high baseline frequency of headaches7
Medications containing barbiturates or opioids are associated with
a 2-fold increase in risk for progression to transformed migraine
In patients with episodic migraine, the annual incidence of
transformed migraine is 2.5%
To catch up a bit, as nosology changes for good or bad, transformed migraine is the term for what happens when episodic migraine changes or
is transformed to chronic migraine. MOH is a risk factor for transformed
migraines, as is duration of the disease, life stress, female gender, and
even brain injury.
Q3 | 2013
Lastly, the diagnosis of “probable migraine” per the IHS5 indicates
that a headache is missing one of the features needed to fulfill all
criteria for a migraine. I will leave the sense of such a definition to
the reader.
When treating chronic migraine with MOH, Diener suggests counseling followed by topiramate or onabotulinumtoxinA, and then admission to a detoxification program if necessary. He feels that counseling would be sufficient in 50% of patients.9 The author notes that
treatment with the Raskin protocol in an interdisciplinary headache
center is more appropriate.10
Finally, prior to dealing with the actual migraine headache, it is important to understand that children who experience physical and
emotional abuse or neglect are more likely to have migraine and
headaches as adults. There appears to be a “dose-response relationship between abuse and headache.” Growing evidence suggests that
genes are involved in either increased vulnerability or resilience in
response to early stressful experiences.11-13
e
MiGRAiN
here are 5 phases of migraine, although not every
attack or every person has all p \