European headache federation consensus on the definition of resistant and refractory migraine Developed with the endorsement of the European Migraine & Headache Alliance (EMHA)

• Published in: Journal of headache and pain Vol. 21; no. 1; p. 76
• Main Authors: Sacco, Simona, Braschinsky, Mark, Ducros, Anne, Lampl, Christian, Little, Patrick, van den Brink, Antoinette Maassen, Pozo-Rosich, Patricia, Reuter, Uwe, de la Torre, Elena Ruiz, Sanchez Del Rio, Margarita, Sinclair, Alexandra J., Katsarava, Zaza, Martelletti, Paolo
• Format: Journal Article
• Language: English
• Published: Milan Springer Milan 16-06-2020
• Subjects: Activities of Daily Living; Analgesics - therapeutic use; Consensus; Consensus Article; Europe - epidemiology; Female; Humans; Internal Medicine; Male; Medicine; Medicine & Public Health; Middle Aged; Migraine Disorders - diagnosis; Migraine Disorders - drug therapy; Migraine Disorders - epidemiology; Neurology; Pain Medicine; Pain, Intractable - diagnosis; Pain, Intractable - drug therapy; Pain, Intractable - epidemiology; Tryptamines - therapeutic use; Europe; Chronic migraine; Intractable migraine; Resistant migraine; Migraine; Refractory migraine
• ISSN: 1129-2369; 1129-2377
• DOI: 10.1186/s10194-020-01130-5

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.