The Challenge of Diagnosing Refractory Migraine

Experts don't agree on what defines this condition

Generally, migraines that are not relieved by acute migraine therapies or prevented by preventive treatments are called refractory migraines, although medical experts have not yet reached a consensus on a precise definition. In some cases, refractory migraine is used synonymously with chronic migraine, or referred to as intractable migraine.

"Refractory" refers to a lack of response to treatment. For people with refractory chronic migraines, symptoms can severely impact their quality of life and daily functioning.

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What Constitutes a Refractory Migraine

In 2008, the Refractory Headache Special Interest Section (RHSIS) and the American Headache Society (AHS) set out to define criteria for refractory chronic migraine.

The criteria include the following:

  • Symptoms must be consistent with those defined by the International Classification of Headache Disorders for migraine or chronic migraine.
  • Headaches need to interfere significantly with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy.

While accepted by many doctors, others maintain that refractory migraine is no different than chronic migraine.


The RHIS and AHS also require the following to make a diagnosis of refractory migraine:

  • Patients must fail to find relief from preventive migraine medicines, alone or in combination, from two to four drug classes including beta‐blockers, anticonvulsants, tricyclics, and calcium channel blockers.
  • Patients must also fail to find relief from abortive migraine medicines, including a triptandihydroergotamine (DHE, intranasal or injectable formulation), and either nonsteroidal anti‐inflammatory drugs (NSAIDs) or a combination analgesic. To meet the qualifications, an appropriate dose of medication must be administered for at least two months at optimal or maximum‐tolerated dose, unless terminated early due to adverse effects.

The definition also takes into consideration whether the headache qualifies as a medication overuse headache. This can occur when someone takes a headache pain reliever for 10 to 15 or more days per month, for more than three months. Other variables that need to be considered are the severity of these migraines and the level of disability they cause.


It's difficult to outline definitive treatments for refractory migraine since there is no agreed-upon definition of what the condition is.

In a 2014 review, the European Headache Federation (EHF) set out to redefine refractory chronic migraine once again in the hopes that this would create a more clear, widespread, and consistent definition to be utilized in future research studies.

The EHF suggests that patients try Botox (onabotulinumtoxinA) as a preventive strategy and not arrive at a diagnosis of refractory migraine unless this treatment fails. (Botox has been found to be very effective in treating chronic migraines.)

EHF is also in favor of guidelines on specific and appropriate dosages of migraine preventive medications, as people may take a medication at a dose that is too low to really be effective, which then gets labeled as "not working" or "failed" by a doctor.

Another study, published in 2018 in Current Pain and Headache Reports, investigated the effect of neuromodulation techniques on refractory migraine and found the results promising.

Again, though, since some doctors equate refractory migraine with chronic migraine, traditional treatments for chronic migraine may also be suggested.

A Word From Verywell

If you suffer from what seem to be refractory migraines, try not to be discouraged. Finding relief will require patience and some degree of trial and error. The right neurologist or headache specialist should work with you to seek out an effective treatment as well as suggest lifestyle modifications and strategies that may help you avoid migraine triggers.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

By Colleen Doherty, MD
 Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis.