What is a chronic migraine? Symptoms, causes, treatments and myths debunked

Migraines affect around 10 million adults in the UK alone, with attacks taking a huge toll on people's work, family and social lives. While chronic migraines are less common, the impact is even greater.

But despite migraines overall being more prevalent than epilepsy, asthma and diabetes, says Dr Michael Long, GP headache specialist and education fellow at the National Migraine Centre, "it receives a fraction of the research budget of other conditions" and is "a long way from being fully understood".

So, here we consult both Dr Long and Steph Weatherley, senior information and support advisor at The Migraine Trust, about what we do know about chronic migraines, common misconceptions, and how to manage and treat them.

What are chronic migraines?

"Migraine attacks can be very debilitating and migraine is the second leading cause of years lived with disability in the world [and the highest among females under 50]," says Dr Long. Symptoms typically involve a combination of headache, nausea, vomiting, and sensitivity to noise, light or smell.

Migraines may be considered a disability under the Equality Act 2010, but it depends on how bad they are, how often you have them and the impact on your day-to-day life.

"Chronic migraine is defined as having headache on 15 or more days per month of which eight should be migraine-like," adds Dr Long.

"With attacks on less than 15 days per month, it is usually called episodic migraine. For those that have a diagnosis of chronic migraine they have typically started with episodic migraine, which has become more frequent over time," he explains.

Chronic migraine symptoms

If you have chronic migraine your symptoms may include:

• Frequent headaches

• Increased sensitivity to light, sound or smells

• Nausea

• Vomiting

• Some people experience an aura (such as visual disturbances, problems with speech, numbness or pins and needles)

• Dizziness

• Vertigo

"There is not necessarily any difference between episodic and chronic migraine. The difference is in frequency of attacks and clearly the more attacks you have the higher the impact can be on someone's quality of life," Dr Long points out.

Weatherley says the severity and impact also differ between each person. "However chronic migraine can have a huge impact on your daily life. Chronic migraine is related to greater disability and has a huge impact on your physical, social and work life. It can also have a huge impact on your relationships."

That said, it is still possible to live a full life doing what you enjoy if you learn how to manage them and are able to adapt things – like work – to help meet your needs.

Overusing acute medication can cause chronic migraines

"One of the most common reasons for episodic migraine becoming chronic migraine can be the overuse of acute medication such as simple analgesia (Paracetamol or Ibuprofen), but most commonly it occurs when people are using opiate-based products such as Codeine or a migraine-specific treatment called a Triptan," Dr Long explains.

"If someone uses any acute medication for more than two three days per week for three or more months they can develop a disorder called medication overuse headache (MOH). This is where the medication itself causes a daily headache. This usually happens slowly over time without the person realising it is happening and it is an important feature in headache clinics."

However, Dr Long also said: "The pattern of chronic migraines will vary depending on individual circumstances and can be affected by age, hormones, stress, anxiety, bereavement and other health conditions. A person with migraine will experience peaks and troughs in the frequency and severity of their migraine throughout their lifetime."

Dr Long says another difficult time for migraine can be around perimenopause, when people with previous episodic migraine can develop more chronic symptoms.

"Genetics also almost certainly play a part in setting your migraine threshold and for some people lifestyle can have an impact but neither of these fully explain this," he adds.

Migraine triggers

Why can things like food, drink, exercise, hormones and stress trigger migraines for some people?

"In basic terms, Migraine essentially gives you an easily irritated brain and a brain that likes routine. It is a threshold disorder, our threshold for getting an attack is very likely genetically linked and then what are often described as triggers can take us over this threshold," says Dr Long.

"However this is different for every person and varies also at different times in the same person. Despite doing everything 'right' people can still experience attacks. It can impact your life significantly already and therefore I discourage people from trying to avoid things to avoid attacks. This often leads to a worsening quality of life and no improvement in attack frequency."

Weatherley adds, "If you have a migraine, almost anything can be a trigger. This means it can be very difficult to identify your potential triggers. It may also be a combination of a few things that seem to lead to a migraine attack. And a trigger may not lead to a migraine attack every time, which can confuse things even more.

"Keeping a migraine diary can help identify any patterns or potential triggers for your migraine attacks."

Treatments for chronic migraines

"It is thought up to 50% of people with a chronic headache have MOH and the best treatment for this is a detox from acute medication for an eight week period. This can be difficult to do so I would recommend that anyone considering this discusses this with their doctor in the first instance," Dr Long urges.

Weatherley points to two treatment types for migraine – acute treatment and preventive treatment.

"Acute treatment is pain relief medications that can be taken at the time of a migraine. These are typically NSAIDS, aspirin, paracetamol and triptan medications. It is important not to exceed using pain medications for more than 15 days in a month. If a person has four or more migraines a month preventive medication may be an option, and these are taken every day and aim to reduce the frequency and severity of the migraine.

"If a person has tried at least three different preventive medications for their migraine and these have not worked, they can then be referred to a neurologist for further review and treatment options."

In terms of the more 'holistic' treatments, Dr Long says, "There is some evidence that some nutraceuticals [a product derived from food sources] such as Riboflavin (Vitamin B2), Magnesium and Co-Enzyme Q10 can help some patients. Our Heads Up Podcast at the NMC can be a useful resource for more information on this."

Chronic migraine myths

Here, Dr Long debunks four common misconceptions about migraines...

1. 'Migraine is just a headache'

"Migraine is a complex, neurological disorder, of which headache is just one symptom. Other symptoms include aversion to light (photophobia), aversion to noise (photophobia), nausea, vomiting, sensory symptoms, feeling off balance and fatigue. Migraine attacks can have up to four phases and the attack (headache) phase is just one of these. Migraine attacks can last for several days.

"I think the perception that migraine is just a headache also contributes to the stigma and lack of understanding around the severity of migraine."

2. Chocolate causes migraine

"There is no evidence that chocolate specifically triggers a migraine attack. In fact one of the premonitory symptoms of migraine can be the craving of sugar, people then eat chocolate and later develop a headache. However, they were already having an attack anyway and therefore the chocolate is wrongly blamed for the attack.

"As I previously said it is rarely a single trigger but a combination of factors that triggers an attack. An attack can also be triggered several hours prior to even developing the headache so triggers can be very difficult to identify."

3. You have to have an aura (flashing lights) to have migraines

"Only 1/3 people with migraine have aura so the vast majority do not. People often tell me they can’t have migraine as they don’t experience the aura symptoms. We don’t fully understand why some people do get aura while others don’t but it is actually more common to have migraine without aura."

Can chronic migraines be cured?

"Unfortunately at present there is no cure for migraine but certainly there are lots of options available to control migraine attacks. What we aim to do at the National Migraine Centre is to work on a plan that allows people to feel in control of their attacks rather than migraine controlling their life," Dr Long says.

National Migraine Centre offers not-for-profit treatment with leading headache specialists for all those affected by migraine – appointments can be booked directly via its website.

You can call The Migraine Trust's Helpline on 0808 802 0066, open 10am–4pm, Monday to Friday and Thursday evenings, 6-8pm (excluding Bank Holidays).

To find out more about what living with chronic migraines is like in reality, and how it doesn't have to stop you achieving what you want, see Sonya Barlow's story here:

Living with chronic migraines: ‘It felt like I was being hit with a hammer for weeks'