What is the difference between intractable (refractory) and non‑intractable migraine, and between status migrainosus and migraine without status migrainosus?

Definitions: Intractable vs. Non-Intractable Migraine and Status Migrainosus

Non-intractable migraine responds to standard acute therapies (NSAIDs, triptans, or their combination) and resolves within the typical 4–72 hour window, whereas intractable migraine fails multiple appropriate acute therapies despite adequate dosing and early administration, with at least two attacks per month causing disability lasting ≥3 days or requiring acute medication use more than twice weekly. 1

Non-Intractable Migraine

Clinical Characteristics:

• Attack duration remains within the typical 4–72 hour range 2
• Patients achieve pain freedom or significant pain reduction when treated with standard-dose acute medications 2
• Does not require escalation to parenteral therapies or emergency-department visits 3
• Responds predictably to first-line treatments: NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg) for mild-to-moderate attacks, or triptans (sumatriptan 50-100 mg) for moderate-to-severe attacks 2

Intractable (Refractory) Migraine

Defining Features:

• Failure of multiple appropriate acute therapies despite adequate dosing and early administration 1, 4
• At least two attacks per month producing disability lasting ≥3 days 1
• Requires acute medication use more than twice weekly, raising the risk of medication-overuse headache 1
• Frequently associated with progression to chronic migraine (≥15 headache days per month) when inadequately managed 2

Treatment Approach:

• Immediate initiation of preventive therapy is mandatory to break the cycle of frequent attacks 1
• First-line preventive agents include beta-blockers (propranolol 80-240 mg/day), topiramate, or amitriptyline 30-150 mg/day 2, 4
• When first-line preventives fail, escalate to CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) with "strong for" recommendations 2
• For chronic migraine (≥15 headache days/month), onabotulinumtoxinA is the only FDA-approved preventive therapy and should be used as first-line when three oral preventives have failed 1
• Efficacy timelines: oral agents require 2-3 months, CGRP monoclonal antibodies require 3-6 months, and onabotulinumtoxinA requires 6-9 months for full assessment 1

Critical Pitfall:

• Persistent reliance on acute medications fosters medication-overuse headache, necessitating complete withdrawal of overused agents before initiating aggressive preventive therapy 1
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates a vicious cycle 1

Status Migrainosus

Definition:

• A severe, continuous migraine attack persisting >72 hours, producing debilitating functional disability despite treatment 5, 6
• Represents a recognized complication of migraine with or without aura 5

Distinguishing from Intractable Migraine:

• Status migrainosus is defined by duration (>72 hours of continuous attack), whereas intractable migraine is defined by treatment failure pattern (multiple attacks per month failing standard therapies) 1, 5
• Status migrainosus can occur in otherwise well-controlled episodic migraine and may respond to aggressive acute interventions without requiring long-term preventive escalation 1
• Intractable migraine represents a chronic pattern of treatment-resistant attacks, whereas status migrainosus is an acute emergency requiring immediate intervention 5, 6

Acute Management:

• Staged approach combining subcutaneous sumatriptan 6 mg with parenteral dopamine receptor antagonists (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) 5
• Add parenteral NSAIDs (ketorolac 30 mg IV) for synergistic analgesia 5
• Corticosteroids (e.g., dexamethasone) may be added to acute regimens, although supporting evidence is limited 1, 5
• Greater occipital nerve blockade with 1-2% lidocaine can provide adjunctive relief 2, 5
• Dihydroergotamine (DHE) IV has good evidence for efficacy as monotherapy 2, 5

Preventive Therapy After Status Migrainosus:

• Initiate or optimize migraine preventive therapy during or immediately after resolution, employing first-line agents such as beta-blockers (propranolol 80-240 mg/day), topiramate, or candesartan 1
• In patients meeting criteria for chronic migraine (≥15 headache days per month), add third-line preventive options including CGRP monoclonal antibodies or onabotulinumtoxinA 1, 5
• Patients should not be discharged without having preventive therapy initiated or optimized, because status migrainosus signals insufficient migraine control 1

Key Medication Frequency Limits

Universal Rule to Prevent Medication-Overuse Headache:

• All acute migraine medications must be limited to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches 2, 1
• This limit applies equally to NSAIDs, triptans, combination analgesics, and all other acute agents 2, 1
• If a patient requires acute treatment more than twice weekly, immediate transition to preventive therapy is mandatory 1