Refractory chronic migraine: a Consensus Statement on clinical definition from the European Headache Federation

Abstract

The debate on the clinical definition of refractory Chronic Migraine (rCM) is still far to be concluded. The importance to create a clinical framing of these rCM patients resides in the complete disability they show, in the high risk of serious adverse events from acute and preventative drugs and in the uncontrolled application of therapeutic techniques not yet validated.The European Headache Federation Expert Group on rCM presents hereby the updated definition criteria for this harmful subset of headache disorders. This attempt wants to be the first impulse towards the correct identification of these patients, the correct application of innovative therapeutic techniques and lastly aim to be acknowledged as clinical entity in the next definitive version of the International Classification of Headache Disorders 3 (ICHD-3 beta).

The diagnosis and treatment of chronic migraine

“…There is ongoing debate about whether a further subdivision of the diagnosis should be created to specify patients who are refractory to treatment [Martelletti et al 2014]. The broader acceptance of the concept that migraine can be a chronic condition has led to increasing interest in the pathophysiology, epidemiology, and treatment of this condition [Diener et al 2012].…”

Medication overuse and chronic migraine: a critical review according to clinical pharmacology

“…It has been suggested that it derives from insufficiency of the mechanisms stopping the attack, increased cortical excitability, atypical pain perception, and increased susceptibility to trigger factors. Even if refractory migraine has not been included in the ICHD-3b [1], the following criteria have been proposed to be able to classify it: chronic migraine (headache for at least 15 days per month), lack of response to at least two prophylactic treatments, with the right doses and duration and with drugs belonging to four different classes (b-blockers, anticonvulsants, tricyclics and calcium blockers), and lack of analgesic rebound [88,89].…”

“…Among the advantages, there is the fact that, defining migraine as refractory, the patient is not blamed for his/her condition and the physician, who has not been able to treat it, feels relieved. Furthermore, having diagnostic criteria allows defining a group of patients who, even if heterogeneous, could be recruited for clinical trials with the most innovative treatments, pharmacological and non-pharmacological [89]. These trials could also give information to define a therapeutic Table 3.…”

Practical issues of management of patients with chronic migraine. Recommendations from Russian experts

“…Несмотря на значительный прогресс, достигнутый в сфере профилактического лечения мигрени, у боль-шого числа пациентов наблюдается устойчивость к лечению даже в случае терапии, проводимой в соот-ветствии с международными рекомендациями [16]. Кроме того, было показано, что адекватное лечение получает лишь очень небольшая доля пациентов с миг-ренью, что способствует ее хронизации.…”

“…В соответствии с совре-менными критериями, мигрень считается рефрактер-ной [16], если отсутствует эффект или имеются проти-вопоказания к профилактическому лечению не менее чем 3 перечисленными выше рекомендованными препаратами, применяемыми в адекватных дозах на протяжении не менее 3 мес каждый;…”