Diagnosis, pathophysiology and management of chronic migraine: a proposal of the Belgian Headache Society.

Chronic migraine (CM) is a disabling neurological condition affecting 0.5-2 % of the population. In the current third edition of the International Classification of Headache Disorders, medication overuse is no longer an exclusion criterion and CM is diagnosed in patients suffering from at least 15 headache days per month of which at least eight are related to migraine. CM is difficult to treat, and preventive treatment options are limited. We provide a pathogenetic model for CM, integrating the latest findings from neurophysiological and neuroimaging studies. On behalf of the Belgian Headache Society, we present a management algorithm for CM based on the international literature and adapted to the Belgian situation. Pharmacological treatment options are discussed, and recent data on transcranial and invasive neuromodulation studies in CM are reviewed. An integrated multimodal treatment programme may be beneficial to refractory patients, but at present, this approach is only supported by a limited number of observational studies and quite variable between centres.

Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial.

OBJECTIVE: To assess efficacy and safety of trigeminal neurostimulation with a supraorbital transcutaneous stimulator (Cefaly, STX-Med., Herstal, Belgium) in migraine prevention. METHODS: This was a double-blinded, randomized, sham-controlled trial conducted at 5 Belgian tertiary headache clinics. After a 1-month run-in, patients with at least 2 migraine attacks/month were randomized 1:1 to verum or sham stimulation, and applied the stimulator daily for 20 minutes during 3 months. Primary outcome measures were change in monthly migraine days and 50% responder rate. RESULTS: Sixty-seven patients were randomized and included in the intention-to-treat analysis. Between run-in and third month of treatment, the mean number of migraine days decreased significantly in the verum (6.94 vs 4.88; p = 0.023), but not in the sham group (6.54 vs 6.22; p = 0.608). The 50% responder rate was significantly greater (p = 0.023) in the verum (38.1%) than in the sham group (12.1%). Monthly migraine attacks (p = 0.044), monthly headache days (p = 0.041), and monthly acute antimigraine drug intake (p = 0.007) were also significantly reduced in the verum but not in the sham group. There were no adverse events in either group. CONCLUSIONS: Supraorbital transcutaneous stimulation with the device used in this trial is effective and safe as a preventive therapy for migraine. The therapeutic gain (26%) is within the range of those reported for other preventive drug and nondrug antimigraine treatments. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that treatment with a supraorbital transcutaneous stimulator is effective and safe as a preventive therapy for migraine.