European headache federation consensus on the definition of resistant and refractory migraine : developed with the endorsement of the European Migraine & Headache Alliance (EMHA)

Research output: Contribution to journalArticlepeer-review


  • Simona Sacco
  • Mark Braschinsky
  • Anne Ducros
  • Christian Lampl
  • Patrick Little
  • Antoinette Maassen Van Den Brink
  • Patricia Pozo-Rosich
  • Uwe Reuter
  • Elena Ruiz De La Torre
  • Margarita Sanchez Del Rio
  • Zaza Katsarava
  • Paolo Martelletti

Colleges, School and Institutes


Introduction: Despite advances in the management of headache disorders, some patients with migraine do not expe-rience adequate pain relief with acute and preventive treatments. It is the aim of the present document to provide a definition of those migraines which are difficult-to-treat, to create awareness of existence of this group of patients, to help Healthcare Authorities in understanding the implications, and to cre-ate a basis to develop a better pathophysiological understanding and to support further therapeutic advances.

Main body: Definitions were established with a consensus process using the Delphi method.

Patients with migraine with or without aura or with chronic migraine can be defined as having resistant migraine and refractory migraine according to previous preventative failures. Resistant migraine is defined by having failed at least 3 classes of migraine preventatives and suffer from at least 8 debili-tating headache days per month for at least 3 consecutive months without improvement; definition can be based on review of medical charts. Refractory migraine is defined by having failed all of the avail-able preventatives and suffer from at least 8 debilitating headache days per month for at least 6 con-secutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating head-ache is defined as headache causing serious impairment to conduct activities of daily living despite the use of pain-relief drugs with established efficacy at the recommended dose and taken early during the attack; failure of at least two different triptans is required.

Conclusions: We hope, that the updated EHF definition will be able to solve the conflicts that have limited the use of definitions which have been put forward in the past. Only with a widely accepted definition, pro-gresses in difficult-to-treat migraine can be achieved. This new definition has also the aim to increase the understanding of the impact of the migraine as a disease with all of its social, legal and healthcare implications. It is the hope of the EHF Expert Consensus Group that the proposed criteria will stimu-late further clinical, scientific and social attention to patients who suffer from migraine which is diffi-cult-to-treat.


Original languageEnglish
Article number76
Number of pages12
JournalThe Journal of Headache and Pain
Publication statusPublished - 16 Jun 2020


  • migrane, chronic migraine, resistant migraine, refractory migraine, intractable migraine