What are the next steps for a patient with treatment-resistant migraines who has failed multiple therapies?

Management of Treatment-Resistant Migraines

For patients with treatment-resistant migraines who have failed multiple therapies, the next step should be to consider CGRP antagonists (gepants) such as atogepant, rimegepant, ubrogepant, or zavegepant, which have shown high efficacy in resistant cases, before considering surgical intervention. 1

Assessment of Current Treatment Status

• This 25-year-old patient has:
  • Migraines with visual aura (10 days/month)
  • Failed first and second-line medications
  • Failed medication combinations
  • Failed lifestyle modifications
  • Failed Onabotulinum toxin A injections
  • Failed acupuncture
  • Significant impact on quality of life (missing work and social events)

Evidence-Based Treatment Algorithm for Treatment-Resistant Migraine

1. Optimize Current Pharmacological Treatment

• Try a CGRP antagonist if not already attempted

  • Atogepant has demonstrated meaningful clinical benefit in treatment-resistant chronic migraine with a 53% response rate (≥50% reduction in monthly migraine days) at 24 weeks 2
  • Even among patients with previous CGRP-monoclonal antibody failures, 47% achieved significant reduction in migraine days 2

• Consider combination therapy

  • Triptan therapy combined with an NSAID has high-strength evidence for breaking severe migraine attacks 1
  • Ensure proper dosing of current medications (beta-blocker, tricyclic antidepressant)

2. Address Medication Overuse

• Limit acute medication use to prevent medication overuse headache:
  • NSAIDs ≤15 days/month
  • Triptans ≤10 days/month 1
• Evaluate current medication usage patterns and consider a medication "holiday" if overuse is suspected

3. Non-Pharmacological Approaches

• Optimize lifestyle modifications:

  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Regular physical exercise
  • Stress management techniques 1

• Consider complementary approaches:

  • Cognitive behavioral therapy
  • Relaxation techniques
  • Magnesium supplements
  • Riboflavin supplements
  • Coenzyme Q10 supplements 1

4. Consider Surgical Intervention

• Surgical decompression should be considered only after exhausting medical management options
• The patient is requesting "migraine surgery" involving transection of the infraorbital nerve (CPT 64734)
• Important caveat: While the neurosurgeon has recommended this procedure, current evidence and guidelines do not strongly support peripheral nerve surgery as a standard treatment for migraine 3
• The European Headache Federation and European Academy of Neurology consensus statement emphasizes pharmacological approaches rather than surgical interventions for migraine management 3

Risks and Limitations of Surgical Approach

• Limited high-quality evidence supporting efficacy of peripheral nerve surgery for migraine
• Potential complications:
  • Nerve damage leading to numbness or paresthesia
  • Infection
  • Scarring
  • No guarantee of improvement
  • Potential for worsening of symptoms

Recommended Next Steps

1. Trial of atogepant or another CGRP antagonist if not previously attempted, as these have shown efficacy even in treatment-resistant cases 2

2. Comprehensive headache diary review to identify potential triggers and patterns

3. Neuroimaging evaluation to rule out secondary causes, particularly given the treatment-resistant nature of the headaches 1

4. Consider referral to a specialized headache center for multidisciplinary management before pursuing surgical intervention

5. Discuss realistic expectations regarding surgical outcomes and ensure the patient understands the limited evidence base for migraine surgery compared to newer pharmacological options

Conclusion

While the patient is requesting surgical intervention and the neurosurgeon has recommended transection of the infraorbital nerve, current evidence suggests that optimizing medical management with newer agents like CGRP antagonists should be attempted first, as they have demonstrated efficacy even in treatment-resistant cases. Surgical approaches should be considered only after exhausting evidence-based pharmacological and non-pharmacological options.