Intended for healthcare professionals

Clinical Review State of the Art Review

Management of chronic migraine

BMJ 2022; 379 doi: (Published 10 October 2022) Cite this as: BMJ 2022;379:e067670
  1. Alexandra Hovaguimian, assistant professor in neurology1,
  2. Julie Roth, associate professor of neurology, associate professor of medical science2
  1. 1Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
  2. 2Warren Alpert Medical School of Brown University, Brown University, Providence, RI, USA
  1. Correspondence to: A Hovaguimian ahovagui{at}


Chronic migraine is a neurologic disorder associated with considerable disability, lost productivity, and a profound economic burden worldwide. The past five years have seen a dramatic expansion in new treatments for this often challenging condition, among them calcitonin gene related peptide antagonists and neuromodulatory devices. This review outlines the epidemiology of and diagnostic criteria and risk factors for chronic migraine. It discusses evidence based drug and non-drug treatments, their advantages and disadvantages, and the principles of patient centered care for adults with chronic migraine, with attention to differential diagnosis and comorbidities, clinical reasoning, initiation and monitoring, cost, and availability. It discusses the international guidelines on drug treatment for chronic migraine and evaluates non-drug treatments including behavioral and complementary therapies and lifestyle modifications. Finally, it discusses the management of chronic migraine in special populations, including pediatrics, pregnancy, and older people, and considers future questions and emerging research in the field.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: Both authors were involved in the development of the intellectual content, literature review, research, manuscript preparation, editing, and review.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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