Steps to manage treatment-refractory migraine in adults

Refractory migraine (RM) is characterized by a lack of response to both migraine-specific and repurposed treatments, significantly impairing quality of life. Risk factors for RM include, among others, overuse of symptomatic medications, nonadherence to treatment and comorbid conditions that limit the use of anti-migraine medications.

This critical perspective addresses the diagnosis and management of patients with RM. It also highlights the best practices tailored to this complex condition, serving as a valuable tool for physicians.

Management demands specialized, holistic approach that considers patient preferences and may deviate from conventional evidence-based practices. Diagnosis requires thorough evaluation to exclude conditions like cluster headaches or trigeminal neuralgias. Treatment integrates symptomatic, interim, and prophylactic strategies. Symptomatic options include triptans, ditans, and gepants, often combined with NSAIDs or antiemetics, but gepants are first-line option because of their low risk for medication overuse headache. Interim treatments, intended to bridge to prophylactic therapy, might involve steroids or long acting triptans. Prophylactic treatments favor migraine-specific medications due to their superior tolerability and effectiveness. Non-pharmacological approaches are also encouraged while continuous monitoring and reassessment after initial treatments are essential, recognizing that RM may recur after a temporary improvement phase.