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Table 2 Proposed criteria for refractory chronic migraine

From: Identifying and managing refractory migraine: barriers and opportunities?

Criteria Definition
A. Primary Diagnosis 1. ICHD-III chronic migraine
2. Medication overuse headache excludeda
B. Refractory Failure to respond to 5 classes of preventive treatments (including 2 from 1 to 3b):
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 migrainec
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 effectsd
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
  1. CGRP calcitonin gene related peptide, ICHD International Classification of Headache Disorders, SNRI Serotonin-noradrenaline reuptake inhibitor
  2. aPatients who overuse abortive treatments can be included provided medication overuse headache has been excluded
  3. bApplicable if available in the local healthcare system
  4. c2 class I or 2 class II based on American Academy of Neurology Scheme for classification of evidence [19]
  5. dOptimum dose defined as that used in the controlled trials demonstrating efficacy or as outlined by local treatment guidelines
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