Transformed Migraine: What Is It?

Transformed migraine has a major impact on people's quality of life and daily activity. Sufferers are more likely to suffer from depression and anxiety.

Written and verified by the doctor Mariel Mendoza.

Last update: 22 March, 2023

Transformed migraine is what is known today as chronic migraine. It refers to the presence of a tension-type headache for 15 days or more per month in a patient with a history of episodic migraines for at least 3 months.

It is the most frequent form of a chronic daily headache.

Sufferers have a history of episodic migraines that begin in their second or third decade of life. Progression is usually gradual, but abruptness has been described in 15-30% of people.

Treatment is complex and should focus on pain prevention as well as lifestyle changes. The transformation of episodic migraine is associated with analgesic abuse and should be considered in the approach.

How is chronic or transformed migraine defined?

The concept of transformed migraine comes from the evolution from episodic migraine (less frequent) to chronification. In general, the condition loses some of the characteristics of migraine, resembling tension-type headaches. Episodes are more frequent, but less intense.

According to the International Headache Society and its criteria published in 2006, the diagnosis of transformed migraine requires the following:

• 15 days or more of headaches (tension-type or migraines) per month, for a minimum of 3 months.
• 8 days or more of headache per month for 3 months, meeting 2 of the following 4 characteristics: unilateral location, throbbing, moderate to severe intensity, aggravated by physical activity; and with 1 of the associated symptoms (nausea, photophobia, phonophobia). Or when it’s treated with ergotamine or triptans, it prevents migraine symptoms from developing.
• 5 or more previous attacks of episodic migraines (usually without aura).
• Not associated with analgesic abuse or other causes.

Symptoms

Because it’s considered a chronification of episodic migraine, the symptoms are the same:

• Unilateral headache, with throbbing character
• Sensitivity to light or sound (photophobia and phonophobia)
• Nausea and vomiting

The presence of aura prior to the onset of pain is not so frequent in these cases.

Sometimes, it can be indistinguishable from tension-type headaches. Thus, the coexistence of migraine and tension features led to the hypothesis of a relationship that includes them in the concept of mixed headache or migraine-tense headache complex.

As time goes by, headaches usually worsen in frequency, but lessen in severity. Until it eventually evolves into a chronic daily or near-daily headache, with overlapping features of tension-type headache and classic migraine.

It’s often associated with analgesic abuse, sleep disturbances, depression, and anxiety. That’s why it’s considered that stress, the presence of traumatic factors or tobacco and alcohol consumption may contribute to the chronification of episodic migraines.

Risk factors

Risk factors for developing transformed migraine include the following:

• Stress
• Female gender
• Genetic tendency
• Caffeine consumption
• Poor sleep hygiene
• History of episodic migraine
• Hormonal changes associated with menopause
• Psychiatric disorders, such as anxiety or depression
• Abuse of analgesics to treat acute headache attacks

Among these, the last factor is of particular importance. Analgesic abuse is defined as taking these medications for 15 days or more per month, in the case of non-opioid analgesics, or 10 days or more per month in the case of triptans, ergotamine, opioids and combined analgesics.

In order to properly classify transformed migraine, rescue analgesics should be discontinued for 2 months.

Treatment of transformed migraine is complex

Treatment of transformed migraine requires preventive medication, lifestyle changes, and the elimination of triggers. However, its effectiveness isn’t immediate and may be delayed up to 3-6 weeks from its initiation.

Emergency drugs, including non-opioid analgesics such as ergotamine and triptans, shouldn’t be recommended. The preventive approach includes the use of the following medications:

• Tricyclic antidepressants (nortriptyline) or selective serotonin reuptake inhibitors (fluoxetine), which also improve depression, anxiety and associated sleep disorders.
• Beta-blockers (atenolol, metoprolol and propanolol).
• Anticonvulsants (topiramate and valproic acid). Contraindicated in women of childbearing age.
• Botulinum toxin injection (especially useful in those who don’t tolerate daily oral medication).
• Monoclonal anti-calcitonin gene-related peptide antibodies, such as erenumab, fremezumab, galcanezumab, and eptinezumab.

In general, it is necessary to combine drugs with different mechanisms of action to control symptoms. Antidepressants are often associated with beta-blockers, for example.

Nonsteroidal anti-inflammatory drugs, triptans and ergotamines are recommended to treat acute episodes of pain in people who don’t abuse analgesics. In addition, habit adjuvants should be included, such as regulating sleep schedules, avoiding known triggers, and being consistent with mealtimes.

Cognitive therapies (relaxation, stress management) have some effectiveness. Dietary measures are also recommended, such as discontinuing caffeine use, as well as smoking.

Migraine transformed can be disabling

As a daily or near-daily headache, it affects the quality of life and mood. Therefore, in addition to having an impact on daily life, it exposes to overuse of medications to improve painful attacks.

That’s why prescribed medicine should be limited and shouldn’t be used more than once or twice a week. In addition, those suffering from transformed migraine very often experience psychiatric disorders, for which psychotherapy could be useful.