8 Common Causes of Chronic Migraines—and How to Manage Them
Medication overuse and disrupted sleep are just two common causes of chronic migraines. Find out how to treat them and find pain relief.
The agony of chronic migraines
One migraine is bad enough. Especially since symptoms, including severe headache, nausea and vomiting, and sensitivity to light and sound, can keep you in misery for up to three days if left untreated.
It’s even worse when migraines become so frequent that you experience an attack during half—or more—days of the month. This is known as a chronic migraine.
What is a migraine?
Nearly 40 million people in the United States get migraines, a neurological condition that affects 18 percent of women, 6 percent of men, and 10 percent of children, according to the Migraine Research Foundation.
To have a migraine is an unpleasant experience, to say the least. An attack feels like throbbing pain on one or both sides of the head and often comes with nausea, vomiting, dizziness, tingling and numbness, and light, sound, and smell sensitivity.
Migraines can radically affect your functioning, keeping you out of work or away from time spent with loved ones.
Suffice it to say migraines are no ordinary headaches.
“Everyone has a threshold for developing a migraine,” says Lauren R. Natbony, MD, assistant professor of neurology at the Icahn School of Medicine at Mount Sinai in New York City.
Those who get migraines more often are thought to have a genetically more sensitive (or irritable or excitable) brain, but a trigger—hormonal fluctuations, lack of sleep, a skipped meal, dehydration, stress—is what tips the brain into an attack.
Episodic versus chronic migraines
When it comes to chronic migraines, the defining trait is how often you’re having an attack.
While episodic migraines can occur up to 14 days per month, chronic migraines involve at least 15 headache days per month, with eight of those days having migraine features, explains Dr. Natbony.
Migraine features may refer to a severe headache or other chronic migraine symptoms, such as nausea or light sensitivity.
It’s officially dubbed chronic when frequent attacks have been going on for three months. According to the Migraine Research Foundation, more than four million adults have chronic migraines.
Causes of chronic migraines
The ultimate (and unfortunate) takeaway is that more migraines lead to more migraines. Here are some of the most common causes of migraines.
More frequent migraines
Migraines start as episodic attacks—you might have a few days here or there with head pain.
“As the frequency increases to eight to 10 days per month, then you have a higher risk of your migraines transforming into chronic migraines,” says Dr. Natbony.
Before a migraine becomes chronic, doctors prefer to get people into treatment.
One of the more common things Dr. Natbony sees in her practice? Overuse of headache medication.
“Taking more medication can cause more headaches,” she says.
This specifically happens once you inch toward the threshold of 10 migraine days per month. At that point, taking ibuprofen or other migraine rescue medications (such as triptans) can trigger what’s called medication overuse headache.
Essentially, the very medication that was supposed to stop your migraine causes it.
That can leave you feeling stuck. Do you try to endure the symptoms, which can be agonizing, or attempt to get relief with these medications? This cycle can put you in a really bad spot and advance your migraine toward chronic.
Migraines that aren’t treated properly
It’s easy to try to treat your migraines yourself, especially if they can somewhat be controlled with over-the-counter medication. However, once you surpass six migraine days per month, Dr. Natbony advises going on preventative meds.
“Otherwise, the frequency can creep up. Without preventative strategies, it’s difficult to make improvements in migraines,” she says.
Depression and anxiety
People with chronic migraines are also more likely to have symptoms of depression and anxiety, according to the American Migraine Foundation (AMF).
The AMF also notes that the most effective way to treat chronic migraines in people who also have mental disorders is to treat anxiety and/or depression at the same time.
Irregular sleeping patterns and not getting enough sleep are commonly seen in people with migraines. But the science on why they’re linked isn’t clear. Do migraines trigger poor sleep, or do you have a sleep disorder that is increasing your migraine frequency?
According to the Sleep Foundation, people with migraines are more likely to struggle with poor sleep compared to those with other headache disorders.
And those who experience sleep disturbances and high levels of stress are more likely to experience severe and frequent migraines, per a study in the journal Pain.
If you’re a fan of caffeinated beverages and are prone to migraines, you may want to cut back.
A small study published in 2019 in The American Journal of Medicine suggests that drinking three or more caffeinated beverages a day increases the likelihood of migraines. One serving size of caffeinated beverages was defined as six to eight ounces of coffee or tea and 12 ounces of caffeinated soda.
This effect was not seen for those who drank one to two drinks per day. However, when people who typically drank less than one serving of caffeine daily had one or two beverages, their migraine risk went up.
The study did have limitations, including the small sample size, relying on self-reported caffeine consumption, and not accounting for the differences in caffeine one beverage can have compared with another.
The best way to determine if caffeine is a trigger for you is to see if your migraines are more frequent after having caffeine. You can then adjust your intake accordingly.
Other risk factors
Along with poor treatment, migraine medication overuse, and mood disorders, being obese and undergoing stressful life events are associated with the development of chronic migraine, notes 2016 research in Nature Reviews Neurology.
Just as women are more likely to have migraines, they are also more likely to have chronic migraines.
Middle-aged adults between 40 and 49 years old are at a higher risk for chronic migraine too.
Where to find help for chronic migraines
It’s fine to see your primary care physician for the occasional migraine.
“Your primary care doctor can be a great first person to see for lower-frequency migraines. When attacks are becoming more frequent, I suggest seeing a headache specialist,” says Dr. Natbony.
These specialists are often neurologists, and they’re specifically trained in the nuances of migraines and the use of certain therapies.
The AMF has a find-a-doctor search that can help you locate a migraine specialist near your area.
(Here are the signs you’re having a silent migraine.)
How to treat chronic migraines
There are two basic types of medication for migraines: migraine-stopping medications and preventive medications.
You’ll take migraine treatment meds when you have a migraine. They include nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans. Preventive medications help prevent attacks from happening in the first place.
In the case of chronic migraines, however, it is highly recommended that you start a preventative medication, says Dr. Natbony.
The goal of preventive medications is not to prevent migraines completely, as it is a chronic condition. The goal, instead, is management.
“Preventive medications decrease headache frequency and disability,” says Stephen D. Silberstein, MD, professor of neurology at Thomas Jefferson University and director of the Jefferson Headache Center in Philadelphia.
There are a variety of preventive migraine drugs to choose from, including beta-blockers, calcium channel blockers, antidepressants, and anticonvulsants.
“I think about what side effect of the drug I can take advantage of,” says Dr. Silberstein. For example, if a patient is depressed, he may recommend an antidepressant, which will not only help prevent migraines but also treat depression.
There are four additional preventive medications that are given via a monthly injection that can treat chronic migraines.
“These can work to reduce the number of migraine days quickly—within the first weeks of using them—but maximum efficacy is around four to six months,” says Dr. Natbony.
- erenumab (Aimovig)
- galcanezumab (Emgality)
- fremanezumab (Ajovy)
- eptinezumab (Vyepti)
Botox, or onabotulinumtoxinA injections, is a Food and Drug Administration-approved treatment for adults who have chronic migraines. But there’s a catch, explains Dr. Natbony.
Insurance won’t cover these injections unless you have started and failed at least two classes of oral medications to control migraines for a minimum of two months.
Of course, she points out, it’s not a patient who fails a medication, but a medication that fails the patient. Otherwise, that puts too much undue blame on someone who has migraines.
Botox for chronic migraine is given once every three months, though it can take a few cycles to see improvement, Dr. Natbony says.
Lifestyle changes for chronic migraines
If you’re especially susceptible to migraines, you’ll want to be extra vigilant about practicing the healthy lifestyle habits that defray migraines. Dr. Silberstein recommends:
- Setting your alarm for the same time every morning
- Drink coffee at the same time each day
- Eat regular meals
- Stay well hydrated
- Drink alcohol in moderation
Because stress is believed to be a common trigger for migraines, participating in activities that help you build resilience and manage stress is incredibly important.
Dr. Silberstein often recommends yoga, Pilates, and meditation.
Next, find out if you should try CBD for migraines.
- Migraine Research Foundation: "Raising Money for Migraine Research"
- Current Pain and Headache Reports: "Defining the Differences Between Episodic Migraine and Chronic Migraine"
- Stephen D. Silberstein, MD, professor of neurology at Thomas Jefferson University and director of the Jefferson Headache Center in Philadelphia
- Nature Reviews Neurology: "Chronic migraine: risk factors, mechanisms and treatment"
- Lauren R. Natbony, MD, assistant professor of neurology at the Icahn School of Medicine at Mount Sinai, New York City
- American Migraine Foundation: "Preventive Treatments"
- AMF: "Depression and Anxiety in Migraine Patients"
- Pain: "Stress and sleep duration predict headache severity in chronic headache sufferers"
- American Journal of Medicine: "Prospective Cohort Study of Caffeinated Beverage Intake as a Potential Trigger of Headaches among Migraineurs"