Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance

Simona Sacco*, Christian Lampl, Antoinette Maassen van den Brink, Valeria Caponnetto, Mark Braschinsky, Anne Ducros, Patrick Little, Patricia Pozo-Rosich, Uwe Reuter, Elena Ruiz de la Torre, Margarita Sanchez Del Rio, Alexandra J. Sinclair, Paolo Martelletti, Zaza Katsarava, Genci Cakciri, Pavllo Djamandi, Serla Grabova, Gleni Halili, Jera Kruja, Altin KuqoDiana Naco, Aida Quka, Ladjola Stefanidhi, Gentian Vyshka, Ilirjana Zekja, Osvaldo Bruera, Dilver Gómez, Brenda Guitian, Juan Carlos Roma, Ike Leon Chen, Samira Bashirova, Maxim Linkov, Daan Van Den Abbeele, Geraldine Vanderschueren, Roberta Araujo, Renato Arruda, Antônio Catharino, Jovana Ciriaco, Amauri Dalla Corte, Ricardo Dornas, Bernardo Felsenfeld, André Fonseca Taufner, Yara Fragoso, Rubens Hurtado, Daniel Isoni Martins, Renata Londero, Luciano Melo, Kelton Stivenson Mignoni, Paulo Victor Sgobbi De Souza, Olena Tsurkalenko, On behalf of the Burden and Attitude to Resistant and Refractory (BARR) Study Group

*Corresponding author for this work

Research output: Contribution to journalArticleResearchpeer-review

27 Citations (Scopus)


Background: New treatments are currently offering new opportunities and challenges in clinical management and research in the migraine field. There is the need of homogenous criteria to identify candidates for treatment escalation as well as of reliable criteria to identify refractoriness to treatment. To overcome those issues, the European Headache Federation (EHF) issued a Consensus document to propose criteria to approach difficult-to-treat migraine patients in a standardized way. The Consensus proposed well-defined criteria for resistant migraine (i.e., patients who do not respond to some treatment but who have residual therapeutic opportunities) and refractory migraine (i.e., patients who still have debilitating migraine despite maximal treatment efforts). The aim of this study was to better understand the perceived impact of resistant and refractory migraine and the attitude of physicians involved in migraine care toward those conditions. Methods: We conducted a web-questionnaire-based cross-sectional international study involving physicians with interest in headache care. Results: There were 277 questionnaires available for analysis. A relevant proportion of participants reported that patients with resistant and refractory migraine were frequently seen in their clinical practice (49.5% for resistant and 28.9% for refractory migraine); percentages were higher when considering only those working in specialized headache centers (75% and 46% respectively). However, many physicians reported low or moderate confidence in managing resistant (8.1% and 43.3%, respectively) and refractory (20.7% and 48.4%, respectively) migraine patients; confidence in treating resistant and refractory migraine patients was different according to the level of care and to the number of patients visited per week. Patients with resistant and refractory migraine were infrequently referred to more specialized centers (12% and 19%, respectively); also in this case, figures were different according to the level of care. Conclusions: This report highlights the clinical relevance of difficult-to-treat migraine and the presence of unmet needs in this field. There is the need of more evidence regarding the management of those patients and clear guidance referring to the organization of care and available opportunities.

Original languageEnglish
Article number39
JournalJournal of Headache and Pain
Issue number1
Publication statusPublished - Dec 2021
Externally publishedYes


  • Migraine
  • Migraine care
  • Refractory migraine
  • Resistant migraine


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