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Chronic migraine (CM) is a frequent and challenging condition for practicing neurologists. It affects around 2% of adults and its prevalence in middle-aged women reaches 5%.1 Management of CM is generally unsatisfactory and largely not evidence-based, in part because until recently CM has not been considered a true entity, but mostly a consequence of analgesic overuse. Evidence that distinguishes the conditions includes findings that only one-third of CM patients in the general population overuse symptomatic medications and that preventives for CM work better than analgesic withdrawal2 (and even in the absence of analgesic withdrawal3). These results support the idea that CM is a biological entity possibly due to a still unknown genetic background.
As a direct consequence of this rapidly evolving concept, specific guidelines for clinical trials in CM were developed in 2008,3 which have allowed demonstration that topiramate4 and onabotulinumtoxinA5 are efficacious over placebo in CM. In fact, analgesic withdrawal, which should not be forgotten in the presence of medication overuse, improves CM together with these preventives. While very encouraging, these interventions may not be enough for numerous CM patients. From a mean of …
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