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Current Concepts in Refractory Migraine

  • HEADACHE (JR COUCH, SECTION EDITOR)
  • Published:
Current Treatment Options in Neurology Aims and scope Submit manuscript

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.

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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.

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Authors and Affiliations

  1. Lankenau Medical Center and Lankenau Institute for Medical Research, 100 Lancaster Avenue, Wynnewood, PA, 19096, USA

    Elliott Schulman MD

  2. Neurology, Boston University School of Medicine, 72 East Concord Street, Neurology C-329, Boston, MA, 02118, USA

    Brian E. McGeeney MD, MPH

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  1. Elliott Schulman MD
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Correspondence to Elliott Schulman MD.

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Schulman, E., McGeeney, B.E. Current Concepts in Refractory Migraine. Curr Treat Options Neurol 15, 40–55 (2013). https://doi.org/10.1007/s11940-012-0206-5

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  • DOI: https://doi.org/10.1007/s11940-012-0206-5

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