Chronic migraine means having headaches on at least 15 days a month for more than three months, with at least 8 of those days showing features of migraine. It affects roughly 2% of people, and it can take over work, family life and plans. Treatment focuses on prevention, on getting acute medicines right, and on identifying whether overuse of painkillers is keeping headaches going. When standard preventives have not worked, options include botulinum toxin, anti-CGRP therapy, nerve blocks and, in very carefully selected people, occipital nerve stimulation.
What is chronic migraine?
Migraine is more than a bad headache. It often involves moderate to severe throbbing pain, sensitivity to light and sound, nausea, and sometimes aura. In chronic migraine the attacks blend into a near-constant pattern of headache days. It often starts as episodic migraine and becomes more frequent over time, and factors such as regular use of acute medicines, poor sleep, stress and other pain conditions can play a part.
Chronic migraine can be hard to sort out from other headache types, and different conditions can co-exist. Diagnosis rests on your history and a neurological examination, and your GP or neurologist may already have confirmed it.
How we assess chronic migraine
Dr Poply asks about your headache pattern, triggers, current and past medicines, and how migraine affects daily life. She will ask you to keep a headache diary if you have not already, because it shows how many days you are affected and how often acute medicines are used. We usually review earlier assessments and scans from your GP or neurologist. Where the picture is unclear or red flags are present, a neurology opinion is recommended before treatment goes further.
Treatment options
Acute medicines used carefully
Triptans and simple painkillers work best when used early in an attack and not too often. Regular use on many days each month can lead to medication overuse headache. Reviewing how you use these medicines is often one of the most useful first steps.
Preventive medicines
NICE lists preventives such as topiramate or propranolol as first choices, with amitriptyline as an option. Each takes several weeks at an adequate dose to judge, and side effects are a common reason for stopping. If you have tried several, that history matters for what comes next.
Botulinum toxin type A
Botulinum toxin is given as a series of small injections around the head and neck, repeated about every 12 weeks. NICE recommends it for adults with chronic migraine who have not responded to at least three preventive medicines and whose medication overuse has been managed. It reduces headache days in some people, not everyone, so we review the response after the first courses before continuing.
Anti-CGRP treatments
Calcitonin gene-related peptide (CGRP) is involved in migraine pain. Monoclonal antibodies that block CGRP or its receptor are given by injection, usually monthly or every three months, and are aimed at people who have not responded to other preventives. NICE has recommended several of these for people who have tried at least three preventive treatments, and the criteria differ by drug. Newer oral CGRP-blocking medicines, called gepants, are also available. Dr Poply offers anti-CGRP therapy for headache patients.
Occipital and other nerve blocks
A local anaesthetic, sometimes with steroid, placed near the greater occipital nerves at the back of the head can settle a headache cycle for some people, and helps show whether these nerves are involved in your pain. Effects are often temporary. Other blocks, such as sphenopalatine ganglion block, may be considered for certain headaches and facial pain.
Occipital nerve stimulation (ONS)
For chronic migraine that has not responded to preventives, botulinum toxin or CGRP treatment, occipital nerve stimulation may be considered. Thin leads are placed under the skin over the occipital nerves at the back of the head and connected to a small implanted generator. It is done in stages, with a trial first.
The evidence needs to be presented honestly. In the ONSTIM feasibility study, 39% of people receiving adjustable stimulation had a response at three months, against 0% on medical management, but lead migration occurred in around a quarter of participants, and the study was funded by the manufacturer. NICE’s 2013 guidance concluded that there is some short-term efficacy but very little long-term evidence, and that the procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Dr Poply’s practice includes occipital nerve stimulation for chronic migraine with autonomic symptoms and for cluster headache, and it is discussed only after other options have been tried and, where appropriate, with neurology input.
Cluster headache and other headaches
Cluster headache is a different condition, with severe one-sided pain around the eye in clusters or as a chronic pattern. The ICON trial, published in The Lancet Neurology in 2021, studied occipital nerve stimulation for medically intractable chronic cluster headache. If you have cluster-type headaches, your first step should be confirmation of the diagnosis and access to the right acute treatments, such as high-flow oxygen and injectable triptans.
What to expect at your consultation
- Bring a headache diary if you have one, along with your medicine history and previous scan or clinic letters.
- We look at how many headache days you have, which medicines you have tried and at what doses.
- Dr Poply explains which options are open to you, including their benefits, risks and realistic chances of helping.
- If a device is being considered, a trial period comes first, and we discuss what monitoring is needed.
About your specialist
Dr Kavita Poply is a Consultant in Pain Medicine and Neuromodulation at St Bartholomew’s Hospital, London, and a Reader at Queen Mary University of London. She runs a refractory headache clinic, and her practice includes botulinum toxin for chronic migraine, anti-CGRP therapy, occipital and peripheral nerve blocks and occipital nerve stimulation.
Frequently asked questions
Q.1 What is the difference between migraine and chronic migraine?
Ans. Migraine that happens on fewer than 15 days a month is called episodic. Chronic migraine means headache on 15 or more days a month for over three months, with at least 8 of those days showing migraine features. Chronic migraine affects roughly 2% of people, and it is often treated differently, including with botulinum toxin or CGRP therapy.
Q.2 Is Botox for migraine available on the NHS?
Ans. NICE recommends botulinum toxin type A as a treatment option for adults with chronic migraine who have not responded to at least three preventive medicines and whose medication overuse has been addressed. NHS access depends on meeting those criteria and on local services. A private consultation can discuss whether you meet them and arrange treatment.
Q.3 How do anti-CGRP injections work?
Ans. They block CGRP, a molecule involved in the pain of migraine, or the receptor it acts on. They are given by injection, usually monthly or every three months, as a preventive. They help many people, but not all, and they are generally considered after other preventive medicines have not worked. Eligibility rules differ between individual drugs.
Q.4 Can painkillers make migraine worse?
Ans. Yes. Using acute medicines on many days each month can lead to medication overuse headache, where the pain treatment keeps the headaches going. Triptans and combination painkillers carry a lower threshold than simple painkillers. If you take medicine for headaches on most days, a review with a specialist is worthwhile before starting a new preventive.
Q.5 What is occipital nerve stimulation for migraine?
Ans. It is a treatment in which thin leads under the skin at the back of the head deliver mild electrical pulses to the occipital nerves. NICE has said the evidence shows some short-term benefit but little long-term data, and that it should only be used with special arrangements for governance, consent and audit or research. It is reserved for carefully selected people with intractable chronic migraine.