Table 1 Previous clinical definition of refractory chronic migraine
Intractable headache (Goadsby (2006) | RHSIS criteria (AHS 2008) | Refractory Migraine (after D’Amico 2008) |
|---|---|---|
Failed an adequate trial of regulatory approved and conventional treatments according to local national guidelines | A. ICHD-II migraine or chronic migraine | CM patients for whom adequate trials of preventive therapies at adequate doses have failed to reduce headache frequency and improve headache-related disability. |
In migraine, failure of at least 4 classes, where 3 should come from 1 to 4 | B. Headaches cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy | MOH patients should also be considered refractory when treatments fail to reduce the consumption of symptomatic drugs. |
1. Beta-blockers | 1. Failed adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes: | Preventive drugs |
2. Anticonvulsants | a. Beta blockers | The greatest possible number of drugs should be tested and found ineffective (or intolerable). |
3. Calcium channel blockers | b. Anticonvulsants | It is not sufficient to try one medication of each pharmacological class. |
4. Tricylic antidepressants | c. Tricyclics | Adequate trial |
5. Other treatments with at least 1 positive randomized controlled trial | d. Calcium channel blockers | Adequate courses of all drugs considered as first-line prophylactics for episodic migraine by international guidelines, and in addition adequate courses of at least some of the drugs considered second- or third-line prophylactic treatments. |
6. Nonsteroidal anti-inflammatory drugs | 2. Failed adequate trials of abortive medicines from the following classes, unless contraindicated: | Trial duration and dosage |
7. Metabolic enhancers, such as vitamin B2 or coenzyme Q10 | • Both a triptan and DHE intranasal or injectable formulation | A 3-month treatment period is required to assess efficacy but it may be useful to continue for a further 3–6 months if there was some improvement during the first 3 months. |
Adequate trial | • Either non-steroidal anti-inflammatory drugs or combination analgesics | Treatment of medication overuse |
Appropriate dose | Adequate trial | Acute medication overuse should be curtailed before starting prophylaxis in patients with chronic headaches. |
Appropriate length of time | Period of time during which an appropriate dose of medicine is administered, typically at least 2 months at optimal or maximum-tolerated dose, unless terminated early due to adverse effects | Treatment of comorbidities |
Consideration of medication overuse | Modifiers | Identification and appropriate treatment of all clinically significant comorbidities is essential before declaring a treatment failure in CM patients. |
Failed | 1. With or without medication overuse, as defined by ICHD-2 | |
No therapeutic or unsatisfactory effect | 2. With significant disability, as defined by MIDAS ≥11 | |
Intolerable side effects | ||
Contraindications to use |