Chronic migraine is a long-term neurological condition that’s defined as experiencing 15 or more headache days per month with migraine symptoms appearing on at least 8 of those days.
If your current treatment method for chronic migraine treatment isn’t helping manage your symptoms, you may be experiencing what is referred to as refractory chronic migraine. This term refers to migraine that does not respond to standard treatments. Although this can impact your quality of life and be frustrating, alternative treatment options are available that can help.
Why refractory chronic migraine is hard to treat
In the United States, between 5% and 30% of people who receive a chronic migraine diagnosis have refractory migraine. In addition to typical migraine symptoms like intense, throbbing headaches and sensitivity to light, refractory migraine symptoms tend to get worse over time.
Refractory migraine can be caused by certain factors, like overusing headache medication or having other health conditions such as depression or anxiety.
People with refractory migraine most likely need a personalized treatment plan because typical migraine treatments don’t often work. This can include preventive drugs, as well as treatments to use during severe migraine attacks.
Refractory chronic migraine treatment options
Many people with refractory migraine can benefit from a newer class of drugs that target the calcitonin gene-related peptide (CGRP) pathway, which is associated with migraine pain. These are often given as a way to prevent migraine from occurring in the first place. A few other treatment options include:
- CGRP monoclonal antibodies: These injectable medications are given on a monthly or quarterly basis to help prevent migraine. Examples include fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti), and erenumab (Aimovig).
- CGRP receptor antagonists: These oral drugs can be used both to prevent migraine and to stop a migraine attack. Examples include atogepant (Qulipta) and rimegepant (Nurtec).
- OnabotulinumtoxinA (Botox): These injections are approved for use every 3 months to help prevent migraine. It can also be used in combination with CGRP monoclonal antibodies for a greater effect.
In addition to medications, there are also neuromodulation devices that use electrical or magnetic pulses to reduce pain signals in the head. There are several options:
- External trigeminal nerve stimulation: A headband device known as Cefaly uses electric currents on the forehead to stimulate nerves.
- Remote electrical neuromodulation: An armband called Nerivio stimulates nerves on the arm.
- Dual-nerve stimulation: A headband known as Relivion stimulates branches of the occipital and trigeminal nerves on the head at the same time.
- Single-pulse transcranial magnetic stimulation (sTMS): A device called Savi Dual delivers a magnetic pulse to stop a migraine attack.
- Noninvasive vagus nerve stimulation: A device known as Gammacore is attached to the neck and sends an electrical current to the cranial nerve.
Two neuromodulation devices that can treat migraine require a procedure for treatment. One is called occipital nerve stimulation (ONS). To use this, a small device is implanted to send electrical impulses to the occipital nerves. The second one is sphenopalatine ganglion stimulation (SPGs). This involves a procedure that implants a device targeting the SPG, a bundle of nerves linked to headache pain.
In addition, other approaches are typically used to treat refractory migraine. These can include behavioral therapies, such as cognitive behavioral therapy (CBT), and lifestyle factors, like staying hydrated and maintaining a regular sleep schedule.
Research has suggested that acupuncture can also be beneficial in treating migraine. A 2020 review and meta-analysis indicates that acupuncture may reduce the frequency of migraine attacks and lower the severity of pain during an attack. However, further research is needed.
If one type of CGRP medication doesn’t help to relieve symptoms, you can ask your doctor about switching to another one. Trying a different class of CGRP-related medication may help, as it targets a different receptor in the body.
Research shows that switching from CGRP medication to another is associated with a reduction in monthly migraine days for some people, particularly over time.
Chronic migraine that doesn’t respond to typical treatments is known as refractory chronic migraine. This common challenge can be treated with a personalized approach. Treatment may involve some type of CGRP-related medication. This can be used in combination with other treatments, such as onabotulinumtoxinA or neuromodulation devices.
If you’re experiencing difficulties with treatment-resistant chronic migraine, you may feel discouraged. However, there are many different options. Discuss alternative treatments with your doctor. Be aware that when you find a combination that works, it can greatly improve your quality of life.