Rational Combination Therapy in Refractory Migraine

Abstract

Refractory migraine (RM) headaches pose important treatment challenges to the patients who live with them and the clinicians who try to treat them. Defined based on the lack of response to acute, preventive, and nonpharmacologic treatment, RM is often treated with a combination of treatments. Although combination therapy for RM has not been systematically studied in randomized trials, clinical experience suggests that a rational approach to RM treatment, utilizing a combination of treatments, may be effective where monotherapy has failed. In this article we briefly identify patient populations appropriate for more aggressive migraine prevention with combination therapy. We then discuss modifiable risk factors and comorbidities in migraine and then focus on the use of rational combination therapy, as well as the duration migraine preventatives should be considered for use. Future research is needed to evaluate the full potential of rational combination treatment as a strategy for treating and ultimately preventing RM.

Controversies in migraine: monotherapy

“…Polytherapy should be considered in those patients with proven unsatisfactory response to most available preventive compounds [15,27]. Before declaring a treatment failure with the monotherapy approach, most-if not allthe first and second line preventive compounds should be tested, and each chosen compound must be used in appropriate daily doses and for adequate time periods.…”

The efficiency of pulsed electromagnetic field in refractory migraine headaches: a randomized, single-blinded, placebo-controlled, parallel group

“…1,2 The International Headache Society introduced refractory migraine (RM) into the International Classification of Headache Disorders 3 (ICHD-3 beta and 2 (ICHD-2) with a prevalence of 5%. [3][4][5] RM characteristics include chronic migraines or migraines without an aura, that significantly interfere with the quality of life in spite of preventive medications. 3,4 Many studies suggest that there are various causes behind migraines such as dysfunction within certain voltage channels in the CNS, neural regulation of the brain stem and cerebral circulation.…”

Proof-of-Principle, Open-Label Prospective Cohort Trial of a Novel Nutraceutical for the Prevention of Refractory Migraine

“…However, a number of patients fail to respond to these "standard" preventive treatments and are considered refractory [2]. Rational combination therapy [3], treatment of co-morbidities, avoidance of modifiable risk factors, and the use of non-pharmaceutical food supplements have been recommended [4][5][6][7][8][9][10], while medication overuse should be discouraged [11,12].…”