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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

Rapid Response:

Re: Management of chronic migraine

Dear Editor

Until very recently we would have shared Hovaguimian and Roth’s cautious optimism for the role of behavioural treatments in the treatment of chronic migraine.[1] Sadly, however, we did not observe any benefit for people with chronic migraine in our randomised controlled trial of a supportive self-management programme for common chronic primary headache disorders with or without medication overuse headache.[2] We included 396 participants with chronic migraine and at one year follow-up the mean difference in Headache Impact Test–6 was -0·7 (95% confidence interval -1·97 to 0·65, P=0·325, intervention vs. controls) amongst this group. The limits of the 95% confidence interval did not include our pre-specified target effect size of a difference of 2.0, effectively excluding any possibility of our intervention having a worthwhile effect.[2] This was despite the intervention being rigorously designed, delivered to a high-standard, and highly valued by participants.[3,4] Our current view is that we need a better understanding of how people with chronic migraine can be helped to live better with their condition, and evidence for effectiveness of any new intervention, before any positive recommendation can be given for behavioural treatments for chronic migraine.

1. Hovaguimian A, Roth J. Management of chronic migraine. BMJ. 2022 Oct 10;379:e067670. doi: 10.1136/bmj-2021-067670.
2. Underwood M, Achana F, Carnes D, et al. A Supportive Self-Management Program for People With Chronic Headaches and Migraine: A Randomized Controlled Trial and Economic Evaluation. Neurology. 2022 Dec 16:10.1212/WNL.0000000000201518. doi: 10.1212/WNL.0000000000201518. Online ahead of print.
3. Patel S, Achana F, Carnes D, et al Usual care and a self-management support programme versus usual care and a relaxation programme for people living with chronic headache disorders: a randomised controlled trial protocol (CHESS). BMJ Open. 2020 Apr 12;10(4):e033520. doi: 10.1136/bmjopen-2019-033520. PMID: 32284387
4. Ellard DR, Nichols VP, Griffiths FE, Underwood M, Taylor SJC; CHESS team (Consortium). Chronic Headache Education and Self-Management Study (CHESS): a process evaluation. BMC Neurol. 2023 Jan 7;23(1):8. doi: 10.1186/s12883-022-02792-1. PMID: 36609224

Competing interests: Professor Underwood reports grants as chief investigator and co-investigator, and personal fees, from National Institute for Health Research, research grants from as co-investigator from Versus Arthritis, Norwegian Medical Research Council, Australian National Health and Medical Research Council, and Stryker Ltd. Professor Ellard reports grants as co-investigator from National Institute of Health Research Professor Sandhu reports grants as chief investigator and co-National Institute of Health Research. She is director of a limited company providing pain management and other psychological services. Professor Matharu reports grants as co-investigator from the National Institute of Health Research, personal fees and honorarium for serving on advisory board from Allergan, honorarium for serving on advisory board from Novartis, personal fees and honorarium for serving on advisory board from Eli Lilly, personal fees and honorarium for serving on advisory board from TEVA, grants from Abbott, grants from Medtronic, grants from electroCore, personal fees and honorarium for serving on advisory board from Salvia, outside the submitted work; In addition, MSM has a patent WO2018051103A1 issued. Professor Taylor reports grants a chief investigator and co-investigator from National Institute of Health Research.

18 January 2023
Martin Underwood
Professor of Primary Care research
Professor David Ellard, Professor Harbinder Sandhu, Professor Stephanie Taylor, Professor Manjit Matharu
Warwick Clinical Trials Unit
Gibbet Hill Road, Coventry, CV4 7AL