Quick Answer
Chronic Migraine treatment is decided by how many days a month are affected rather than by severity. Acute treatment addresses an attack; preventive treatment reduces frequency, and the two use different medications and different logic. Where testing is indicated it is performed in our AANEM-accredited laboratories and read in-house.
Part ofThis guide sits beneath headache and migraine, which covers the study itself, how it is performed and what the report should contain.
how CNS approaches Headache and Migraine →Key Takeaways
- Chronic migraine means fifteen or more headache days a month with migraine features on at least eight.
- Most patients underestimate their count substantially when reconstructing from memory.
- Medication overuse is addressed before or alongside a preventive rather than after.
- Botox requires the threshold; CGRP therapy does not, which is the practical difference between them.
- Response is judged across cycles, and abandoning a preventive after two weeks discards a workable plan untested.
How chronic migraine is treated
Chronic migraine is defined numerically, and that number is what unlocks the treatment options rather than describing how bad it feels.
Chronic migraine means fifteen or more headache days per month, with migraine features on at least eight of those days, sustained over a period rather than in a single bad month.
Establishing the count first
Most patients underestimate their headache days substantially when reconstructing from memory, because milder days do not register as episodes. A month of dates with severity and what was taken is what establishes whether the threshold is met, and its absence is the commonest reason a first appointment ends with a request to return.
Medication overuse before anything is added
A substantial share of chronic migraine is sustained by the acute medication taken for it. Addressing that usually has to come before or alongside a preventive, because a preventive started on top of an unrecognised overuse pattern works against a headwind. It is common, it is not a failure of willpower, and it changes the sequence rather than the destination.
The preventive options, and how they differ
Botox for chronic migraine requires the threshold and is given in-office at fixed sites on a repeating schedule. CGRP therapy does not require the threshold and comes in self-injected, in-office and oral forms. Older oral preventives remain appropriate for many patients and are usually required by insurers first. Which fits depends on frequency, what has been tried at what dose and for how long, other conditions, and whether an appointment or a prescription suits your life.
How response is judged
On the change in monthly headache days across cycles, not on whether the next attack was prevented. Assessment typically needs months, and abandoning a preventive after two weeks is the commonest way a workable plan gets discarded before it has been tested.
| Also considered | How it is distinguished |
|---|---|
| Tension-type headache | Pressing, bilateral pain without nausea, aura or movement sensitivity. |
| Cluster headache | Strictly one-sided, 15 minutes to about 3 hours, with tearing, nasal congestion or a drooping eyelid, and restlessness rather than stillness. |
| Medication-overuse headache | A pattern change: headaches become more frequent as acute medication use rises, and the history rather than a scan identifies it. |
| Secondary headache | Red flags — sudden 'worst-ever' onset, fever with neck stiffness, new deficit, or onset after head injury — prompt urgent imaging rather than a headache diagnosis. |
What the practice does, and what to bring
01
What brings people in
Frequent or changing headaches, attacks that are no longer controlled by what used to work, or a new headache pattern that needs an explanation.
02
What the evaluation settles
Which headache disorder the pattern fits, whether any red flag needs imaging, and which preventive and acute options are appropriate.
03
What you leave with
A named diagnosis where one can be made, a written acute and preventive plan, and a follow-up interval to judge whether it is working.
Bring a month of dates
Which days you had a headache, roughly how severe, and what you took. That single record converts an approximate conversation into a decision, and its absence is the commonest reason a first appointment ends with a request to return.
Medication overuse checked before a preventive is added
Acute headache medication taken frequently enough can sustain the headaches it was taken to relieve. Common, not a failure of willpower, and it changes the plan: addressing it usually has to come before or alongside a new preventive, because a preventive started on top of an unrecognised overuse pattern works against a headwind.
Treatment options performed here
Botox for chronic migraine and CGRP therapy are both available, on the Botox page and the CGRP page. Where pain localises to a specific nerve on examination, a targeted nerve block may apply. Coverage and prior authorisation are completed before the appointment.
How prevention is assessed
On the change in headache frequency across months rather than on whether it stopped one attack. Abandoning a preventive after two weeks is the commonest way a workable plan gets discarded before it has been tested. Practice guidance is from the American Academy of Neurology.
The first 30, 60 and 90 days
Step 1
First visit
History and neurological examination, a review of records and prior imaging, and a decision on which studies are actually indicated. You leave with the plan, not just a referral.
Step 2
Within 30 days
Indicated in-office studies are performed and interpreted by the neurologist who ordered them, in our AANEM-accredited laboratories. Results are explained in plain language.
Step 3
60 to 90 days
Follow-up to judge whether the plan is working, adjust it, and coordinate with your referring clinician. Where a diagnosis needs time to confirm, this is where it is revisited.
Not sure which headache type you have?
Bring a month of dates and what you took. Classification comes before treatment.
The Bottom Line
The number is what unlocks the options. Bring a month of dates, and mention anything you take for headache most weeks.
Frequently Asked Questions
What counts as chronic migraine?
Fifteen or more headache days a month, with migraine features present on at least eight of them. It is a numerical definition rather than a description of severity, and it determines candidacy for several preventive treatments. Episodic migraine, meaning fewer than fifteen headache days a month, is managed differently, so establishing which side of that line you sit on changes which options are open to you.
Why does frequency matter more than severity?
Because treatment decisions run on how many days a month are affected rather than how bad the worst day was. Most people underestimate their count substantially when reconstructing from memory, which is why a month of dates is worth more than any description. A written record of dates is the only thing that settles the count reliably.
Could my sinus headaches be migraine?
Frequently. Migraine activates a pathway producing nasal congestion, facial pressure and tearing, which are exactly the symptoms people attribute to sinuses. Recurrent sinus headache without infection is uncommon, so episodic attacks with clear intervals point toward migraine. Sinus imaging in these patients is frequently normal, and that is often the point at which migraine is finally considered.
Can painkillers make my headaches worse?
Yes. Acute headache medication taken frequently enough can sustain the headaches it was taken to relieve. It is common and not a failure of willpower, but addressing it usually has to come before or alongside a new preventive. The pattern to watch for is acute medication on more than about ten days a month, sustained across several months.
When is a headache an emergency?
When it reaches maximum intensity within seconds, or comes with fever and neck stiffness, new weakness, difficulty speaking or vision loss. Those need an emergency department rather than an appointment. A sudden severe headache brought on by exertion, or a first severe headache after about age fifty, also warrants urgent assessment rather than a routine appointment.
Do I need acute or preventive treatment?
It depends on frequency. Two attacks a month needs effective acute treatment; fifteen headache days needs prevention, and treating the second with only acute medication is how medication overuse develops. Many patients need both, with acute treatment kept for the attacks that break through a working preventive, and the aim is to reduce how often that happens.
Can I be treated if imaging has already been done and was normal?
Yes, and a normal scan is the expected finding in migraine. Imaging looks for a structural cause; it does not diagnose or exclude a headache disorder, which is established from the pattern. Bring the report rather than repeating the scan, because knowing it was normal changes what still needs considering.
Will I have to stop the medication I am using now?
Not abruptly, and not without a plan. Where an acute medication is being taken often enough to be sustaining the headaches, reducing it is planned deliberately alongside starting a preventive, because doing one without the other usually fails. Bring the bottles so the actual pattern can be seen rather than estimated.
How many headache days should I record before coming in?
A month is ideal and two weeks is useful. Record the date, roughly how bad it was, and what you took including anything bought without a prescription. That record is what establishes frequency, and frequency rather than severity decides which treatments are open to you, so it does more work than any description can.
How long does a first appointment take?
Longer than a routine primary care visit, because most of it is history taking and that is the part carrying the diagnosis. A physical examination follows. Allow rather more time in your day than the slot itself suggests, since it is better not to be watching the clock during the examination or the explanation afterwards.
How this page was sourced
Practice facts come from Clinical Neurology Specialists directly: that Botox for chronic migraine and CGRP therapy are both available in-office, and that the practice performs no cosmetic injections and runs no interventional pain programme. Clinical context is sourced to the organisations listed below.
No named agents, response rates, reduction percentages or dosing appear, because selection is a clinical decision and response varies between individuals. Treatment approaches are described by class and mechanism rather than by product. No outcome is promised. Scope is adults 18 and older.
Change log
- 2026-07-28 — page published; clinical content reviewed.
- 2026-07-28 — last reviewed against AAN, AANEM and NINDS guidance; internal links and schema verified.
- Review cadence: quarterly, or sooner if guidance changes.
How to cite this page
Clinical Neurology Specialists. “What is the Trusted treatment for chronic migraine.” Reviewed 2026-07-28. https://www.cnsnevada.com/conditions/headache-migraine/what-is-the-best-treatment-for-chronic-migraine/
References
- American Headache Society — classification and clinical guidance for headache disorders.
- American Academy of Neurology — practice guidance on preventive treatment.
- National Institute of Neurological Disorders and Stroke — the reference catalogue of nervous-system disorders.
This page is for general information about a Clinical Neurology Specialists office and is not medical advice, a diagnosis, or a treatment recommendation. It does not create a physician-patient relationship. Adults 18 and older. For an active stroke, a first-time or prolonged seizure, sudden severe headache, sudden weakness, sudden vision loss, or a head injury with loss of consciousness, call 911 or go to the nearest emergency department.