Chronic Migraine: Diagnosis and Advanced Treatment in Ottawa

Chronic migraine in Ottawa: Accurate diagnosis and specialized treatment options

Chronic migraine is not “just more headaches.” It represents a high-burden form of migraine disease associated with substantial disability, impaired quality of life, and increased healthcare use.

At the Ottawa Headache Centre, we treat chronic migraine as a serious neurological disorder that deserves structured, evidence-based, subspecialty care.

What is chronic migraine and how is it different than episodic migraine

What is the difference between episodic and chronic migraine?

Migraine exists on a spectrum of frequency and burden.

While people often hear the terms episodic and chronic migraine, it is important to understand:

All migraine is a chronic neurological disease.

The terms “episodic” and “chronic” describe migraine frequency and burden — not whether the disease is permanent.

Migraine is biologically chronic. The classification of episodic vs. chronic migraine reflects how many days per month migraine affects you.

Episodic migraine

Headache is experienced less than half of the month

The number of migraine days per month can be high or low

Excellent response to CGRP antagonists, however no proven benefit from Botox®

Chronic migraine

At least 15 days per month are associated with any headache

At least 8 days per month of migraine

High risk of medication-overuse

Excellent response to both Botox® and CGRP antagonists

Chronic migraine represents a state of central sensitization and disease amplification. Many patients describe:

A “background headache” with superimposed severe migraine attacks
Reduced response to acute medications
Brain fog, fatigue, and cognitive slowing
Increased light, sound, or motion sensitivity throughout the month

Do I need a brain scan?

Most patients with a typical history of chronic migrainedo not need a brain scan (e.g., CT scan or MRI). For all patients, we look for signs and symptoms that suggest there might be a secondary cause of headache that need imaging.

Treating chronic migraine in Ottawa

Chronic migraine requires a structured, layered approach that starts with arriving at an accurate diagnosis.

Many patients with chronic migraine underrecognize days with headache leading to an under recognition of chronic migraine. When there are frequent migraine attacks, tracking headache days with a reliable headache diary can help confirm the diagnosis of chronic migraine.

The Ottawa Headache Centre approach to chronic migraine

At the Ottawa Headache Centre we follow a structured systematic approach to managing chronic migraine that has the following pillars:

History and examination

A careful and detailed history is necessary to distinguish chronic migraine from:

high-frequency episodic migraine
chronic tension-type headache
medication-overuse headache
IIH (idiopathic intracranial hypertension)
other secondary causes of headache

Optimize acute medications

We optimize your acute medications to help stop migraine attacks on their tracks. Typically, we will combine medications of multiple classes to give you the flexibility you need to precisely treat different headache types. Acute treatments can be:

Simple analgesics (acetaminophen, NSAIDs)
Triptans
Gepants
Ergotamine
Nerve blocks

We systematically screen for treat for medication-overuse headache.

Preventive treatment

The cornerstone of chronic migraine treatment is effective preventive therapy. Oral preventives typically fall into four categories:

Blood pressure meds: Often the first line of defense.
Antidepressants: Used for their pain-modulating properties, not just mood.
Anticonvulsants: Helping to stabilize nerve excitability.
Nutraceuticals: Evidence-based supplements like magnesium, riboflavin (B2), and coenzyme Q10.

Botox® for chronic migraine

For patients with chronic migraine who do not improve after trialing 2 oral preventives, we offer neurologist and specialist administered Botox® using the PREEMPT protocol: the only proven protocol to effectively treat chronic migraine.

CGRP antagonists for chronic migraine

CGRP antagonists are an excellent alternative to Botox® for selected patients. They can be administered as oral tablets, monthly self-injections, or quarterly intravenous infusions.

Lifestyle and triggers

To improve the effectiveness of treatments we use the SEEDS framework to manage your triggers:

Sleep hygiene (consistent wake/sleep times).

Exercise (steady, non-strenuous movement).

Eat (healthy, balanced, and avoid sugar crashes).

Diary (tracking triggers and frequency).

Stress management (regulating your triggers and their impact on your nervous system).

Next steps

If you suffer from migraine attacks frequently, or find that you have a headache the majority of the time, ask your doctor for a referral to the Ottawa Headache Centre.

Want to learn more about acute migraine treatment? Explore our Acute Treatment Guide.

Need an approach to migraine preventive treatment? We cover the principles of prevention and when to consider starting preventive treatment.

Trying to decide on which migraine-specific preventive is right for you? Take dive into our Botox® for chronic migraine program, and learn more about CGRP antagonists.

Experiencing headache and planning pregnancy, are pregnant, or are in the post-partum period? The Ottawa Headache Centre has a dedicated Headache in Pregnancy program.

Common questions about migraine

What causes migraine?

Migraine is caused by changes in brain processing signals, especially pain signals. It is thought as a network disorder with multiple cogs and factors working together to result in migraine.

Key features include:

Increased sensitivity of pain pathways
Altered signaling involving brain chemicals such as CGRP
Changes in how the brain responds to normal sensory input

Migraine is not caused by brain damage, stress alone, or weak coping skills.

Can episodic migraine turn into chronic migraine?

Yes.

Migraine can change over time, and factors that increase the risk of migraine becoming chronic include:

Frequent inappropriately treated migraine attacks
Overuse of acute pain medications
Poorly controlled migraine triggers
High stress or major life changes
Lack of preventive treatment

Early and appropriate treatment can reduce the risk of progression, and for this reason the International Headache Society's position statement is to offer effective preventive treatment to eligible patients early.

Why do insurers require trying non-specific oral medications before a migraine-specific preventive?

Currently, most plans use step therapy with pre-authorization criteria.

Each insurance plan is different.

Why should I track my migraine attacks?

A headache diary helps identify patterns, triggers, and how well treatments work. It’s also valuable when talking with your clinician about preventive therapy.

What is usually required before CGRP preventives or Botox ® are approved?

Trial of at least two oral preventive medications
Each at a therapeutic dose for ~3 months (varies by insurance)
Documentation of migraine frequency and impact

Coverage varies by insurer.

Once migraine is stable, do I need ongoing specialist care?

Not always. Once stable, care can usually transition to your family doctor and they should continue any relevant renewals.

Can treatment really improve quality of life?