Current Treatment Options in Neurology

, Volume 15, Issue 1, pp 40–55 | Cite as

Current Concepts in Refractory Migraine

HEADACHE (JR COUCH, SECTION EDITOR)

Opinion statement

The Refractory or Intractable Migraine (RM) patient has long been a challenge to all healthcare providers (HCP). Headache specialists have recognized this sub group of patients who remain refractory to treatment. Despite this recognition, there are no formal criteria that characterize RM. This article will attempt to provide treatment approaches, some scientifically based and others that are empiric. A reasonable goal is to lessen disability. Combining the various modalities will improve the chances for successful treatment. The foundation of treatment is an emphasis on wellness. This includes optimizing mood, minimizing stress, practicing good sleep hygiene, and avoiding triggers. All comorbid factors should be addressed, including sleep and mood disorders, chronic neck pain, and obesity. Preventive treatment is necessary in the majority of patients, and a plan for “rescue” approaches is essential. Avoiding medication overuse, particularly narcotics, is advisable. Additional options for treatment include onabotulinumtoxinA, and more invasive modalities, such as neurostimulation. Adjunct treatment including supplements and relaxation may also be considered. Keeping a headache calendar is almost mandatory in management with attention to particular headache triggers, patterns and medication overuse (MOH). A trusting physician–patient relationship is also very important and will enhance compliance and foster communication. Patients often lapse from the management plan and the treating physician should be open minded about continuing care. RM is a long-term disease and requires close physician–patient interaction and cooperation for management of the problem. In those RM patients with multiple comorbidities, a multidisciplinary team should optimize management.

Keywords

Refractory Migraine Intractable Classification Definition Neurostimulation Supplements Sleep disorders Depression Anxiety Risk factors Abortive Prophylaxis Dopamine antagonists Opioids Anticonvulsants Nerve blocks Treatment 

Notes

Acknowledgment

The authors wish to thank Kate Ciavarelli for providing editorial assistance in preparing the manuscript.

Disclosure

Dr. McGeeney has served as a consultant for and received honoraria from Merck & Co., Allergan, MAP Pharmaceuticals, Zogenix, and NuPathe; has received payment for the development of educational presentations (including service on speakers’ bureaus) from Merck & Co., Eli Lilly and Company, Ortho-McNeill, and Pfizer; and holds stock in Pfizer.

Conflicts of Interest

Dr. Schulman has served as a consultant to NuPathe and Zogenix. He is the speakers bureau of Merck and Impax. He has received research funding from NuPathe and has received royalties from Oxford University Press.

References and Recommended Readings

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Goadsby P, Schoenen J, Ferrari M, et al. Towards a definition of intractable headache for use in clinical practice and trials. Cephalalgia. 2006;26:1168–70.PubMedCrossRefGoogle Scholar
  2. 2.
    Schulman EA, Lake III AE, Goadsby PJ, et al. Defining refractory migraine and refractory chronic migraine: proposed criteria from the Refractory Headache Special Interest Section of the American Headache Society. Headache J Head Face Pain. 2008;48:778–82.CrossRefGoogle Scholar
  3. 3.
    Silberstein SD, Dodick DW, Pearlman S. Defining the pharmacologically intractable headache for clinical trials and clinical practice. Headache J Head Face Pain. 2010;50:1499–506.CrossRefGoogle Scholar
  4. 4.
    Robbins L. Refractory headache definition. Headache J Head Face Pain. 2011;51:310–1.CrossRefGoogle Scholar
  5. 5.
    Robbins L. Refractory chronic migraine: long-term follow-up using a refractory rating scale. J Headache Pain. 2012;13:225–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Schulman EA, Lipton R, Peterlin BL, et al. Commentary from the refractory headache special interest section on defining the pharmacologically intractable headache for clinical trials and clinical practice. Headache J Head Face Pain. 2010;50:1637–9.CrossRefGoogle Scholar
  7. 7.
    Irimia P, Palma JA, Fernandez-Torron R, Martinez-Vila E. Refractory migraine in a headache clinic population. BMC Neurol. 2011;11:94.PubMedCrossRefGoogle Scholar
  8. 8.
    Busch V, Gaul C. Exercise in migraine therapy–is there any evidence for efficacy? A critical review. Headache. 2008;48:890–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Bigal ME, Lipton RB. Modifiable risk factors for migraine progression. Headache. 2006;46:1334–43.PubMedCrossRefGoogle Scholar
  10. 10.
    Lipton R, Diamond M, Freitag F, et al. Migraine prevention patterns in a community sample: Results from the American Migraine Prevalence and Prevention (AMPP) study. Philadelphia: American Headache Society 47th Annual Scientific Meeting; 2005.Google Scholar
  11. 11.
    Loder E, Biondi D. General principles of migraine management: The changing role of prevention. Headache. 2005;45:S33–47.PubMedCrossRefGoogle Scholar
  12. 12.
    Evans RW, Williams MA, Rapoport AM, Peterlin BL. The association of obesity with episodic and chronic migraine. Headache. 2012;52:663–71.PubMedCrossRefGoogle Scholar
  13. 13.
    Peterlin BL. Bariatric surgery in obese migraineurs: Mounting evidence but important questions remain. Cephalalgia. 2011;31:1333–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Andress-Rothrock D, King W, Rothrock J. An analysis of migraine triggers in a clinic-based population. Headache. 2010;50:1366–70.PubMedCrossRefGoogle Scholar
  15. 15.
    Sauro KM, Becker WJ. The stress and migraine interaction. Headache. 2009;49:1378–86.PubMedCrossRefGoogle Scholar
  16. 16.
    Dodick DW, Eross EJ, Parish JM, Silber M. Clinical, anatomical, and physiologic relationship between sleep and headache. Headache. 2003;43:282–92.PubMedCrossRefGoogle Scholar
  17. 17.
    Rains JC. Chronic headache and potentially modifiable risk factors: Screening and behavioral management of sleep disorders. Headache. 2008;48:32–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Rains JC, Poceta JS. Headache and sleep disorders: Review and clinical implications for headache management. Headache. 2006;46:1344–63.PubMedCrossRefGoogle Scholar
  19. 19.•
    Rains JC, Poceta JS. Sleep and headache. Curr Treat Options Neurol. 2010;12:1–15. A comprehensive review of sleep and how it applies to headache.PubMedCrossRefGoogle Scholar
  20. 20.
    Sancisi E, Cevoli S, Vignatelli L, et al. Increased prevalence of sleep disorders in chronic headache: A case–control study. Headache. 2010;50:1464–72.PubMedCrossRefGoogle Scholar
  21. 21.
    Griffiths R, Evans S, Heishman S, et al. Low-dose caffeine physical dependence in humans. J Pharmacol Exp Ther. 1990;255:1123–32.PubMedGoogle Scholar
  22. 22.
    Cripe SM, Sanchez SE, Gelaye B, et al. Association between intimate partner violence, migraine and probable migraine. Headache J Head Face Pain. 2011;51:208–19.CrossRefGoogle Scholar
  23. 23.
    Tietjen GE, Brandes JL, Peterlin BL, et al. Childhood maltreatment and migraine (part I). Prevalence and adult revictimization: A multicenter headache clinic survey. Headache. 2009;50:20–31.PubMedCrossRefGoogle Scholar
  24. 24.
    Tietjen GE, Brandes JL, Peterlin BL, et al. Childhood maltreatment and migraine (part II). Emotional abuse as a risk factor for headache chronification. Headache. 2009;50:32–41.PubMedCrossRefGoogle Scholar
  25. 25.
    Tietjen GE, Brandes JL, Peterlin BL, et al. Childhood maltreatment and migraine (part III). Association with comorbid pain conditions. Headache. 2009;50:42–51.PubMedCrossRefGoogle Scholar
  26. 26.•
    McGeeney BE. Acute and urgent treatment of refractory migraine. In: Schulman EA, Levin M, Lake III AE, Loder E, editors. Refractory migraine. Mechanisms and management. New York: Oxford University Press; 2010. p. 116–35.A more comprehensive review of acute treatment in the refractory migraine patient.Google Scholar
  27. 27.•
    Mathew NT. Prophylactic treatment of refractory migraine. In: Schulman EA, Levin M, Lake III AE, Loder E, editors. Refractory migraine. Mechanisms and management. 1st ed. New York: Oxford University Press; 2010. p. 101–15. A more comprehensie review of prophylactic treatment in the refractory migraine patient.Google Scholar
  28. 28.
    Sargent JD, Baumel B, Peters K, et al. Aborting a migraine attack: Naproxen sodium v ergotamine plus caffeine. Headache J Head Face Pain. 1988;28:263–6.CrossRefGoogle Scholar
  29. 29.
    Silberstein SD, Freitag FG, Bigal ME. Migraine treatment. In: Silberstein S, Lipton RB, Dodick DE, editors. Wolf's headache and other head pain. 8th ed. New York: Oxford University Press; 2008. p. 177–292.Google Scholar
  30. 30.
    Scott AK. Dihydroergotamine: A review of its Use in the treatment of migraine and other headaches. Clin Neuropharmacol. 1992;15:289–96.PubMedCrossRefGoogle Scholar
  31. 31.
    Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology. 1986;36:995–7.PubMedCrossRefGoogle Scholar
  32. 32.
    McGeeney BE. Dopamine antagonists and migraine. Drug Dev Res. 2007;68:341–5.CrossRefGoogle Scholar
  33. 33.
    Jones J, Sklar D, Dougherty J, White W. Randomized double-blind trial of intravenous prochlorperazine for the treatment of acute headache. JAMA J Am Med Assoc. 1989;261:1174–6.CrossRefGoogle Scholar
  34. 34.
    Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: Meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336:1359–61.PubMedCrossRefGoogle Scholar
  35. 35.
    Ziegler DK. Opioids in headache treatment: Is there a role? Neurol Clin. 1997;15:199–207.PubMedCrossRefGoogle Scholar
  36. 36.
    Saper JR, Lake AE, Bain PA, et al. A practice guide for continuous opioid therapy for refractory daily headache: Patient selection, physician requirements, and treatment monitoring. Headache J Head Face Pain. 2010;50:1175–93.CrossRefGoogle Scholar
  37. 37.
    Diener H, Bussone G, Oene JCV, et al. Topiramate reduces headache days in chronic migraine: A randomized, double-blind, placebo-controlled study. Cephalalgia. 2007;27:814–23.PubMedCrossRefGoogle Scholar
  38. 38.
    Fontebasso M. Topiramate for migraine prophylaxis. Expert Opin Pharmacother. 2007;8:2811–23.PubMedCrossRefGoogle Scholar
  39. 39.
    Bulut S, Berilgen MS, Baran A, et al. Venlafaxine versus amitriptyline in the prophylactic treatment of migraine: Randomized, double-blind, crossover study. Clin Neurol Neurosurg. 2004;107:44–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Holland S, Silberstein S, Freitag F, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1346–53.PubMedCrossRefGoogle Scholar
  41. 41.
    Lipton RB, Gobel H, Einhaupl KM, et al. Petasites hybridus root (butterbur) is an effective preventive treatment for migraine. Neurology. 2004;63:2240–4.PubMedCrossRefGoogle Scholar
  42. 42.•
    Ashkenazi A, Levin M. Nerve blocks, neurostimulation, and botulinum toxin injection treatment for refractory migraine. In: Schulman EA, Levin M, Lake III AE, Loder E, editors. Refractory migraine. Mechanisms and management. 1st ed. New York: Oxford University Press; 2010. p. 266–92.Excellent practical chapter on the nerve blocks for headache.Google Scholar
  43. 43.
    Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes–prolonged effects from a single injection. Pain. 2006;122:126–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Aurora S, Dodick D, Turkel C, et al. OnabotulinumtoxinA for treatment of chronic migraine: Results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010;30:793–803.PubMedCrossRefGoogle Scholar
  45. 45.
    Diener H, Dodick D, Aurora S, et al. OnabotulinumtoxinA for treatment of chronic migraine: Results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010;30:804–14.PubMedCrossRefGoogle Scholar
  46. 46.
    Lambru G, Matharu MS. Occipital nerve stimulation in primary headache syndromes. Ther Adv Neurol Disord. 2012;5:57–67.PubMedCrossRefGoogle Scholar
  47. 47.
    Magis D, Schoenen J. Advances and challenges in neurostimulation for headaches. Lancet Neurol. 2012;11:708–19.PubMedCrossRefGoogle Scholar
  48. 48.•
    Saper JR, Lake III AE. Inpatient strategies for refractory migraine. In: Schulman EA, Levin M, Lake III AE, Loder E, editors. Refractory migraine: Mechanisms and management. New York: Oxford University Press; 2010. p. 341.This chapter, written by an expert in the field, provides an excellent overview of treating RM.Google Scholar
  49. 49.
    Schulman EA. Historical overview of refractory migraine. In: Schulman EA, Levin M, Lake III AE, Loder E, editors. Refractory migraine. Mechanisms and management. 1st ed. New York: Oxford University Press; 2010. p. 5–18.Google Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Lankenau Medical Center and Lankenau Institute for Medical ResearchWynnewoodUSA
  2. 2.NeurologyBoston University School of MedicineBostonUSA

Personalised recommendations