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Published on: June 2, 2014
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Reaching international consensus on the definition of refractory migraine using the Delphi method
Jennifer Robblee1, Fawad A Khan2,3, Michael J Marmura4
1Department of Neurology, Barrow Neurological Institute, Dignity Health, Phoenix, AZ, USA.
Cephalalgia : an International Journal of Headache
|September 15, 2025
Summary
International experts reached a consensus on definitions for refractory migraine and related conditions. These new categories aim to standardize research and improve clinical decision-making for migraine patients who have not responded to treatments.
Area of Science:
- Neurology
- Headache Medicine
- Clinical Consensus
Background:
- Refractory migraine is common in headache centers but lacks a formal definition in the International Classification of Headache Disorders, 3rd edition (ICHD-3).
- The European Headache Federation (EHF) proposed definitions for refractory and resistant migraine in 2020.
- There is a need for international consensus on the definition of refractory migraine to guide research and clinical practice.
Purpose of the Study:
- To achieve international consensus on the definition of refractory migraine.
- To develop standardized criteria for refractory migraine, probable refractory migraine, resistant migraine, and treatment-responsive migraine.
- To provide a framework for future research and clinical management of difficult-to-treat migraine.
Main Methods:
- A Delphi consensus study involving 20 international headache medicine experts.
- Utilized a focus group and five rounds of expert review based on EHF 2020 criteria.
- Consensus thresholds were defined as >70% for strong agreement, 60-70% for minor agreement, and <60% for no agreement.
Main Results:
- Developed four key categories: refractory migraine, probable refractory migraine, resistant migraine, and treatment-responsive migraine.
- Refractory migraine requires failure of all evidence-based treatment classes; resistant migraine requires failure of at least three classes.
- Probable refractory migraine criteria address treatment access barriers, and treatment-responsive criteria aid research standardization.
Conclusions:
- The four proposed categories can facilitate enrollment in studies on migraine pathophysiology, biomarkers, and treatments.
- Clinically, these criteria will aid decision-making, emphasizing evidence-based treatments and guiding aggressive approaches.
- The criteria may increase recognition of this migraine subgroup's burden, supporting advocacy for specialized care.
