European headache federation consensus on the definition of resistant and refractory migraine

Abstract

Introduction Despite advances in the management of headache disorders, some patients with migraine do not experience adequate pain relief with acute and preventive treatments. It is the aim of the present document to provide a definition of those migraines which are difficult-to-treat, to create awareness of existence of this group of patients, to help Healthcare Authorities in understanding the implications, and to create a basis to develop a better pathophysiological understanding and to support further therapeutic advances. Main body Definitions were established with a consensus process using the Delphi method. Patients with migraine with or without aura or with chronic migraine can be defined as having resistant migraine and refractory migraine according to previous preventative failures. Resistant migraine is defined by having failed at least 3 classes of migraine preventatives and suffer from at least 8 debilitating headache days per month for at least 3 consecutive months without improvement; definition can be based on review of medical charts. Refractory migraine is defined by having failed all of the available preventatives and suffer from at least 8 debilitating headache days per month for at least 6 consecutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating headache is defined as headache causing serious impairment to conduct activities of daily living despite the use of pain-relief drugs with established efficacy at the recommended dose and taken early during the attack; failure of at least two different triptans is required. Conclusions We hope, that the updated EHF definition will be able to solve the conflicts that have limited the use of definitions which have been put forward in the past. Only with a widely accepted definition, progresses in difficult-to-treat migraine can be achieved. This new definition has also the aim to increase the understanding of the impact of the migraine as a disease with all of its social, legal and healthcare implications. It is the hope of the EHF Expert Consensus Group that the proposed criteria will stimulate further clinical, scientific and social attention to patients who suffer from migraine which is difficult-to-treat.

Additive Interaction Between Onabotulinumtoxin-A and Erenumab in Patients With Refractory Migraine

“…Nevertheless, migraine burden decrease was again reported not satisfactory by the patients, once again considering the headache-related disability (by MIDAS) and the symptomatic drug intake. In other terms, our patients fulfilled the European Headache Federation criteria for “refractory migraine” ( 10 ). Although a >30% reduction in headache days can be considered satisfactory, it has been recently argued that with the use of percent reduction, patients may be considered responders but still have a relevant number of debilitating days with headache.…”

“…Indeed, to overcome this problem, the European Headache Federation (EHF) Expert Consensus Group opted to use eight headache days per month as cutoff values. Eight days per month were chosen to consider evidence indicating that moderate disability starts after 4 migraine days per month ( 10 ). Therefore, to achieve a putative additive or synergic interaction, a combined treatment with BTX-A (185 UI quarterly administration) and erenumab (140 mg monthly administration) was started.…”

Early Management of OnabotulinumtoxinA Treatment in Chronic Migraine: Insights from a Real-Life European Multicenter Study

“…1), considering patients who developed a new-onset response and patients who lost their response over time. This was possible because of the large number of included patients selected from international real-life practice; all patients would have fulfilled the recently issued definition of ''resistant migraine'' [21]. As investigators were not aware of the study aim a priori, we can exclude any influence on treatment disposition according to personal expectations.…”

Burden and Attitude to Resistant and Refractory Migraine A Survey From the European Headache Federation With the Endorsement of the European Migraine & Headache Alliance

“…Before starting to ll-out the questionnaire participants were provided with a gure summarizing the de nitions of resistant and refractory migraine and with the link to the published Consensus article [12].…”

“…In order to move forward in the eld of di cult-to-treat migraine patients, the European Headache Federation (EHF) with the endorsement of the European Migraine & Headache Alliance (EMHA) issued a Consensus document to propose criteria to approach those patients [12]. In details, the new de nitions of the di cult to treat migraine included non-response to acute and preventative medications.…”