ST. PETERS, MISSOURI
Our headache doctor sees St. Peters patients at the Natural Bridge Road office, about 14.7 miles and roughly 22 minutes east on I‑70. Chronic migraine is treated with a preventive strategy first and an acute strategy second, including onabotulinumtoxinA injections and the newer CGRP‑targeted treatments.
Fifteen headache days a month is not just a lot of headaches. It is a formal diagnostic threshold that changes the treatment, changes what insurance will authorize, and changes the prognosis — which is why counting matters more than most patients are told.
Getting here from St. Peters
St. Peters is about 14.7 miles west of the Natural Bridge Road office, roughly 22 minutes on I‑70 east over the Missouri River. The trip is predictable outside the afternoon peak, and appointments can usually be scheduled to avoid it.
What is chronic migraine?
The formal definition is headache on fifteen or more days per month for more than three months, with at least eight of those days having migraine features. Below that threshold the diagnosis is episodic migraine.
This is not a bureaucratic distinction. Chronic migraine responds to a different treatment set, carries a different prognosis, and unlocks therapies — onabotulinumtoxinA among them — that are not indicated below the threshold.
It also means that a patient having fourteen headache days a month and a patient having sixteen are treated differently, which sounds arbitrary until you realize the alternative is no threshold at all. Chronic migraine covers the criteria and what follows from them.
Why counting is harder than it sounds
Most people underestimate their headache days substantially. The reason is that the milder days do not get remembered — a two‑out‑of‑ten background headache that was managed with an over‑the‑counter tablet does not feel like a headache day in retrospect, but it counts.
The days that get missed are exactly the ones that matter for the threshold. Someone who reports four bad migraines a month may well have twenty headache days when they actually track it.
This is why a diary is not busywork. A month of honest recording changes the diagnosis in a meaningful share of patients. How to keep a headache diary covers what to record, and how many days explains why the number carries so much weight.
What turns episodic migraine into chronic migraine?
Migraine does not usually become chronic overnight. It transforms over months to years, and several factors are consistently associated with that transformation:
- Frequent use of acute medication, particularly combination analgesics, opioids and butalbital‑containing products
- Untreated or undertreated attacks, where each attack runs its full course
- Obesity, which is an independent risk factor for progression
- Poor or disordered sleep, including untreated sleep apnea
- Depression, anxiety and significant life stress
- Caffeine intake at high levels
Several of these are modifiable, which is the practical point. Transformation is not inevitable and it is partly reversible.
Can overusing headache medication cause daily headaches?
This is the single most important thing to check in anyone with daily or near‑daily headache. Regular use of acute medication more than about ten days a month for triptans, combination analgesics and opioids, or about fifteen days a month for simple analgesics, can itself perpetuate the headache.
The frustrating part is that the medication genuinely works for each individual attack. The problem is the cumulative pattern, and it is invisible from inside it.
Withdrawal produces a period of worse headache before improvement, which is why it needs a plan and support rather than an instruction. A meaningful proportion of patients revert from chronic to episodic once it is addressed. Medication overuse headache covers how it is unwound.
How is chronic migraine treated?
Chronic migraine is treated with a preventive strategy first, an acute strategy second, and both together. Preventives include the older oral options, onabotulinumtoxinA injections for chronic migraine specifically, and the newer CGRP‑targeted treatments, which have changed the field substantially for patients who failed older drugs.
Procedural options sit alongside. Occipital nerve blocks are useful for breaking a cycle and for patients with occipital tenderness, and sphenopalatine ganglion blocks have a role in a subset.
The realistic target is not zero headaches. It is a substantial reduction in frequency and severity, and a return of the days in between. Preventive treatment options covers what to expect from each.
How much improvement should you expect from chronic migraine treatment?
The target in chronic migraine is not zero headache days, and setting that expectation is how patients conclude that effective treatment has failed. The usual benchmark in preventive treatment is a fifty percent reduction in headache days, and reaching it is a good result rather than a partial one.
What that means practically is a patient going from twenty headache days a month to ten. Ten is still a lot of headache. It is also the difference between missing most of a month and missing a third of it, and that difference is where the value sits.
Improvement also shows up in places a headache count does not capture — attacks that respond to acute treatment when they did not before, shorter attacks, less severe ones, and fewer days spent recovering afterward. Tracking those alongside the count gives a truer picture of whether a treatment is working. How many days covers the counting, and what chronic headache means covers the longer arc.
Frequently asked questions from St. Peters patients
How long does a preventive take to work?
Most oral preventives need eight to twelve weeks at an adequate dose before their effect can be judged. Stopping at three weeks because nothing has changed is the most common reason a preventive is written off as ineffective when it was never given a fair trial.
Is Botox only for chronic migraine?
The evidence and the indication are specifically for chronic migraine at fifteen or more headache days a month. It has not shown the same benefit in episodic migraine, which is one of the practical reasons the threshold matters. Botox for chronic migraine covers the protocol.
Can chronic migraine go back to episodic?
Yes, and it does in a meaningful share of patients, particularly when medication overuse is addressed and an effective preventive is found. The transformation runs both ways, which is worth knowing when the picture feels permanent.
What if I have already tried several preventives?
Failing older oral preventives is common and it is the exact situation the CGRP‑targeted treatments were developed for. When nothing has worked covers the sequence from there.
How do you stop migraines that keep coming back?
Start with medication overuse, the single most important thing to check in anyone with daily or near-daily headache. Then build a preventive strategy first and an acute strategy second: older oral preventives, onabotulinumtoxinA for chronic migraine, or CGRP-targeted treatments. Occipital nerve blocks can help break a cycle. The realistic goal is fewer and milder headache days, not zero.
Why should I keep a headache diary?
Because most people undercount their headache days. The mild days managed with an over-the-counter tablet do not feel like headache days afterward, but they count. Someone who reports four bad migraines a month may have twenty headache days once they track it. A month of honest recording changes the diagnosis for a meaningful share of patients, and the fifteen-day threshold changes treatment.
Do weight and sleep affect chronic migraine?
Yes. Obesity is an independent risk factor for migraine progressing from episodic to chronic, and poor or disordered sleep, including untreated sleep apnea, is consistently linked to that transformation. So are frequent acute medication use, depression, anxiety, stress and high caffeine intake. Several of these can be changed, which is the practical point: the transformation is not inevitable and is partly reversible.
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12174 Natural Bridge Rd, Suite 304
St. Louis, MO 63044