Chronic Migraine: A Case of Successful Treatment

A 23-year-old man presented to the outpatient clinic with severe headaches.
The patient described painful sensations mostly in the forehead area, right eye, eyebrow, and temple, with the left side rarely affected. He felt like his head was pulsating or being pounded upon. The intensity of the pain reached 7–9 points out of 10 on the Visual Analog Scale (VAS).

He couldn’t sleep at night due to the pain and would sit at the computer. Mornings lacked freshness, and he struggled through the workday. Additionally, he lost his appetite, eating only because he felt he had to.

The pain worsened when hungry, stressed, or with disrupted sleep patterns (e.g., waking up later on weekends). It also intensified after consuming chocolate and red wine.

During attacks, he preferred lying down, covered with a blanket, in a quiet and dark environment, as sounds and bright light exacerbated discomfort. Walking and any other activities worsened the pain.

Taking two NSAID tablets somewhat relieved the pain, but it didn’t always fully subside. A month before seeking help, his neighbor suggested using Triptans—special migraine medications. He tried them during an attack, and the pain disappeared within 25 minutes.

The pain first appeared after finishing school during exams, mainly triggered by emotional stress, occurring no more than 1–2 times a month.

In the past year, after breaking up with his girlfriend, the pain became more frequent, with 16–18 episodes per month for three months before seeking help. He consumed more than a pack (20 tablets) of painkillers in 30 days.

He had never consulted doctors before and considered himself healthy.

There were no chronic illnesses.

His mother often suffered from headaches, sometimes lying with a cold cloth on her head for whole days. After turning 50, the pain occurred much less frequently. There was no history of heart attacks, strokes, or cancer in the family.


During the visit, the young man spoke softly and slowly, pausing. Tears filled his eyes when asked about relationships. He was reluctant to discuss it further.

According to the Hospital Anxiety and Depression Scale (HADS): anxiety—8 points, depression—11 points. On the Hamilton scale, he scored 17 points (mild depressive disorder).

At his mother’s insistence, he underwent various tests. The results of MRI of the brain, MR angiography, ultrasound Doppler scanning of the brachiocephalic arteries, and blood and urine analyses were within normal limits.

MRI of the cervical spine showed initial signs of degenerative changes.
Chronic migraine without aura. Headache induced by medications. Depressive disorder.


The patient was prescribed:
• Prophylactic migraine therapy, considering the frequency of attacks and the abuse of analgesics; preference was given to botulinum toxin therapy—injections of botulinum toxin type A according to the PREEMT protocol.
• Selective serotonin reuptake inhibitors (SSRIs) as antidepressants for at least one year.

He was also advised to attend cognitive-behavioral therapy sessions, keep a headache diary, maintain sleep hygiene, avoid combined analgesics, and manage migraine attacks with appropriate doses of medication.

Three weeks after receiving botulinum toxin injections, the young man noticed a reduction in the frequency of attacks. The pain subsided within the first half-hour after taking a Triptan tablet.

He tolerated the antidepressant well, experiencing mild nausea in the first week. He attended several psychotherapy sessions. He reported having no sleep problems for 5 days a week.

Three months after botulinum toxin therapy, alongside antidepressant treatment, the frequency of headache attacks decreased to 5 times a month. He took Triptans three times. He started sleeping well, and his appetite returned. HADS and Hamilton scale scores decreased to 1 and 5 points, respectively.
This clinical case demonstrates the importance of prescribing preventive treatment for chronic migraine, especially when comorbid depressive disorder is present. Depression exacerbates migraine and contributes to its chronicity, thus requiring therapy, including antidepressants. Interestingly, treating both pathologies simultaneously yields faster and longer-lasting positive effects.