From the Guidelines
Refractory migraines should be treated with a stepped approach, starting with first-line medications such as beta blockers (e.g., propranolol), topiramate, or candesartan, as recommended by the most recent guidelines 1. When managing refractory migraines, it's essential to consider the frequency and impact of the headaches on the patient's daily life.
- The treatment approach should prioritize preventive treatment in patients who experience migraines on ≥2 days per month despite optimized acute treatment 1.
- First-line medications, including beta blockers (e.g., atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan, should be considered as the initial treatment option 1.
- If the first-line medications are ineffective, second-line medications such as flunarizine, amitriptyline, or sodium valproate (in men) can be considered 1.
- For patients who do not respond to first- and second-line treatments, CGRP monoclonal antibodies should be considered as a third-line treatment option 1.
- Additionally, neuromodulatory devices, biobehavioural therapy, and acupuncture can be used as adjuncts to acute and preventive medication or as stand-alone preventive treatment when medication is contraindicated 1.
- Lifestyle modifications, such as regular sleep patterns, stress management, consistent meals, and trigger avoidance, are also crucial in managing refractory migraines.
- It's essential to work with the patient to develop a personalized treatment plan, taking into account their specific needs and medical history, to improve their quality of life and reduce the frequency and severity of migraines.
From the FDA Drug Label
to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day.
The treatment for refractory migraines (recurrent severe headaches) is onabotulinumtoxinA (BOTOX), which is used to prevent headaches in adults with chronic migraine who have 15 or more days each month with headache lasting 4 or more hours each day 2.
From the Research
Treatment Options for Refractory Migraines
The treatment for refractory migraines, which are recurrent severe headaches, can involve various medications and therapies. Some of the key treatment options include:
- Preventive medications such as beta-blockers, amitriptyline, divalproex, and topiramate, which have been shown to be effective in reducing the frequency, duration, or severity of migraine attacks 3, 4
- Anticonvulsants like zonisamide, which has been found to be efficacious in patients with frequent refractory migraine, with a response rate of 44% 5
- OnabotulinumtoxinA, which has shown efficacy in large placebo-controlled randomized trials for the treatment of chronic migraine 6
- Alternative treatment options like sodium valproate, gabapentin, tizanidine, fluoxetine, and memantine, which may be considered for patients who do not respond to first-line treatments 6
- Non-pharmacological therapies such as acupuncture, biofeedback, relaxation therapy, and cognitive behavioral therapy, which may be beneficial for some patients 6
Considerations for Treatment
When selecting a treatment for refractory migraines, several factors should be considered, including:
- The patient's medical history and presence of comorbid conditions 3, 4, 7
- The frequency and severity of migraine attacks 3, 7
- The patient's preferences and response to prior treatments 3, 7
- The potential adverse events associated with each treatment option 3, 4, 7
Special Considerations
In some cases, patients with refractory migraines may require more aggressive treatment, such as:
- Intravenous dihydroergotamine regimen for medically refractory chronic migraine 6
- Occipital nerve stimulation, which is a promising treatment with ongoing studies defining its use 6
- Surgical treatments like bariatric surgery and deactivation of trigger points, which may be considered for select patients 6