Identifying and managing refractory migraine: barriers and opportunities?

Table 2 Proposed criteria for refractory chronic migraine

Criteria	Definition
A. Primary Diagnosis	1. ICHD-III chronic migraine 2. Medication overuse headache excluded^a
B. Refractory	Failure to respond to 5 classes of preventive treatments (including 2 from 1 to 3^b): 1. Topiramate 2. Minimum of two quarterly injections of Onabotulinumtoxin A 3. CGRP pathway monoclonal antibody 4. Betablockers (Propranolol, Metoprolol, Timolol) 5. Tricyclic antidepressant (Amitriptyline) 6. SNRI (Venlafaxine) 7. Sodium valproate/Divalproex sodium 8. Other pharmacological preventive treatments with established efficacy in migraine^c
C. Adequate Trial	At least 2 month trial at an optimum or maximum tolerated dose (excluding the time taken for the titration o the dose), unless terminated early due to side effects^d
D. Failed Trial	1. Failure to respond to drug (< 50% reduction in frequency and/or severity of monthly migraine days) 2. Intolerable side effects 3. Contraindication to use

CGRP calcitonin gene related peptide, ICHD International Classification of Headache Disorders, SNRI Serotonin-noradrenaline reuptake inhibitor
^aPatients who overuse abortive treatments can be included provided medication overuse headache has been excluded
^bApplicable if available in the local healthcare system
^c2 class I or 2 class II based on American Academy of Neurology Scheme for classification of evidence [19]
^dOptimum dose defined as that used in the controlled trials demonstrating efficacy or as outlined by local treatment guidelines

ISSN: 1129-2377