Medical Interventions for Migraine That Has Become Difficult to Treat

Migraine is an episodic painful disorder which can gradually chronify, and is among the most common neurological diseases in clinical practice. Such process is often accompanied by the appearance of acute drugs overuse. Chronic migraine (CM) constitutes migraine’s natural evolution in its chronic form and involves headache frequency of 15 days/month, with features similar to those of migraine attacks. Migraine given by drugs overuse, defined by ICDH-II in 2004 (and revised in 2005) as MOH, represents a common and debilitating disorder, which can be defined as generation, perpetuation and persistence of intense chronicmigraine caused by the frequent and excessive use of (symptomatic) drugs for at least 3 months, for a certain number of days permonth, giving an immediate relief. Migraine’s progression from an episodic to a chronic form is generally influenced by baseline headache frequency, inappropriate use of rescue selfmedication, absence of referral to headache centers during the worsening period in terms of headache days frequency, as well as by lack of education in avoiding trigger factors or inadequate lifestyle rhythms (fasting, sleepiness). In MOH sufferers, the only treatment of choice is represented by drug withdrawal. Successful detoxification is necessary to ensure improvement in the headache status when treating patients who overuse acute medications. Possible therapeutic agents in CM re-prophylaxis after detoxification are OnabotulinumtoxinA and Topiramate. The future in relapse prevention of CM complicated by MOH consists in considering how drugs currently used, such as triptans and emerging therapies, present responsivity profiles related to well-defined genetic polymorphisms.