The patient should be treated with topiramate for chronic migraine, which is headache occurring on 15 or more days per month for more than 3 months. Chronic migraine is characterized by increasingly frequent attacks of migraine that are eventually accompanied by an interval milder headache. By definition, on at least 8 days of the month, the headache of chronic migraine must be severe, possess migraine features, or respond to migraine-specific therapy. The interval headache may have no migraine features and appear to be a tension-type or sinus headache. A medication overuse element is often present and may interfere with the efficacy of preventive and acute migraine treatments. Headache frequency and acute medication use of greater than 10 days per month are significant risk factors for transformation to chronic migraine. Because the development of secondary brain pathology also occasionally may contribute to the transformation to chronic migraine, MRI of the brain is indicated.
Topiramate has level A evidence of effectiveness in treating episodic migraine. Topiramate and onabotulinumtoxinA are the only agents that have shown efficacy in studies of chronic migraine. Topiramate is less expensive than onabotulinumtoxinA.
Carbamazepine is the drug of choice for treating trigeminal neuralgia but has shown no effect on migraine prevention.
Although the serotonin-norepinephrine reuptake inhibitor venlafaxine has demonstrated benefit in migraine prevention studies, no such data are available for duloxetine, which is in the same drug class and is used to treat major depressive disorder and generalized anxiety disorder.
Propranolol has level A evidence of effectiveness in the prevention of episodic migraine but has the potential to worsen both depression and asthma. No evidence supports it use for chronic migraine.
Verapamil is the treatment of choice in cluster headache prevention. The drug, however, has neither level A (effective) nor level B (probably effective) evidence supporting its use in migraine prevention.