How do you manage seemingly treatment-resistant chronic migraine?

First, let's define refractory migraine. The most recent and strict diagnosis that I use was a proposal by the European Headache Federation (EHF):

Refractory Migraine

1. Established diagnosis of 1.1 Migraine without aura and/or 1.2 Migraine with aura or 1.3 Chronic migraine according to ICHD-III criteria.

2. Debilitating headache for at least 8 days per month for at least 3 months.

3. Failure and/or contraindication to all classes with established evidence for migraine prevention, given at an appropriate dose for an appropriate duration.

They define a debilitating headache impairing daily activity despite at least 2 ineffective triptan trials. Their recognized drug classes are antidepressants (amitriptyline and venlafaxine), antiepileptics (top...

I agree with Dr. @Dr. First Last's very measured and complete response. However, I would like to add that when a "refractory" headache presents, as with any seemingly treatment-resistant condition, it is critical to re-examine the diagnosis. It is not uncommon to find that treatment-resistant headache patients diagnosed with chronic migraine actually have other chronic conditions such as spontaneous intracranial hypotension, thyroid disorders, hemicrania continua, etc. A careful history and examination and some testing can often uncover a missed primary or secondary headache requiring a different treatment plan.

There are various answers and approaches to a patient with refractory chronic migraine. Firstly, it's essential to determine if the patient has already undergone multi-modality treatments, such as combining botulinum toxin injections and a CGRP mAb. While SSRIs have been mentioned, it's worth noting that they lack strong evidence for migraine relief compared to SNRIs, which have stronger support in clinical studies. Has the patient tried neuromodulation?

Furthermore, it's critical to assess other potential contributing factors, such as the patient's medication regimen and lifestyle habits. For instance, is medication overuse headache a concern here? Are there regular use of over-the-counter pain relievers or opioids? What about sleep patter...

Typically “resistant migraine” patients have a mixture of three different types of headaches; migraines, tension headaches, and medication overuse headaches. The first step is to separate these three headaches and treat each individually. Of course, patients who come in with intractable HAs must be convinced that a significant number of their headaches are from overuse of medications and begin to taper, while temporarily using something like injections of DHE. Never (I mean “never”) use procedures until the complete patient profile is identified and addressed.