Chronic Migraine

Headache medicine is a subspecialty within neurology. A headache specialist knows all current treatment options and has experience with prior authorization for CGRP medications. The American Headache Society (americanheadachesociety.org) has a specialist finder.

You need to document headache days to qualify for Botox or CGRP antibodies. Migraine Buddy (free app) is the most comprehensive. Track: date, duration, intensity, medications taken, and possible triggers.

With chronic migraine, you need preventive medication. Acute-only treatment leads to medication-overuse headache. Start with generics (topiramate, amitriptyline, propranolol) or ask about CGRP antibodies if you've failed older preventives.

Apply through the manufacturer's co-pay program: Aimovig Ally Support, Teva's Ajovy program, Lilly Cares for Emgality, Pfizer Access 360 for Nurtec. All bring monthly cost to $0 for commercially insured patients.

Consistent sleep schedule, regular meals, hydration, aerobic exercise, and magnesium supplementation (400mg/day) all have evidence for migraine reduction. Biofeedback and CBT have clinical evidence. These complement medications but don't replace preventive therapy for chronic migraine.

Episodic migraine means fewer than 15 headache days per month. Chronic migraine is 15 or more headache days per month for more than 3 months, with at least 8 meeting migraine criteria. Chronic migraine is more disabling, harder to treat, and qualifies for Botox (only approved for chronic migraine). Many develop chronic migraine from episodic through overuse of acute pain medications (medication-overuse headache or MOH).

CGRP treatments (Aimovig, Ajovy, Emgality, Nurtec, Qulipta) are the first medications developed specifically for migraine prevention. Older options — beta-blockers, tricyclics, anticonvulsants — were developed for other conditions. CGRP drugs have advantages: faster onset, fewer side effects, and no weight gain or cognitive effects. The disadvantage is cost (~$700/month vs. <$30 for generics). Most headache specialists try older generics first due to cost.

Yes. Botox for chronic migraine (not cosmetic Botox) is covered by most commercial insurance and Medicare Part B. Requirements: diagnosis of chronic migraine (15+ headache days/month) and documentation that at least two preventive medications were tried and failed. Prior authorization is usually required. AbbVie My Botox Now program helps with co-pay.

MOH occurs when acute migraine medications are taken too frequently — triptans ≥10 days/month, analgesics ≥15 days/month, opioids ≥10 days/month. MOH paradoxically worsens headache frequency and makes preventive medications less effective. If you take acute medication more than 10 days per month, you likely have MOH. Treatment requires weaning off the overused medication, often with preventive therapy.

Common triggers: hormonal changes, sleep irregularity, stress, skipping meals, certain foods (red wine, aged cheese, processed meats), dehydration, bright lights, strong smells, and weather changes. Keep a headache diary (Migraine Buddy app) to identify your top 3–5 triggers. Avoid overly restricting life to avoid triggers — the migraine brain is hypersensitive to change itself.