Achieving Consensus Definitions for Refractory and Resistant Migraine: Jennifer Robblee, MD, MSc

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"We've landed with a definition for refractory migraine. And born out of what the European Headache Federation came up with, we also have a definition for resistant migraine. Then we also defined what a treatment responder actually is, and then the concept of probable refractory migraine."

Although refractory migraine is commonly encountered in tertiary headache centers, the International Classification of Headache Disorders, 3rd edition (ICHD-3) does not currently provide diagnostic criteria for the condition. Over the years, several definitions have been proposed, including a 2020 framework from the European Headache Federation (EHF) outlining criteria for both refractory and resistant migraine. To address the lack of standardization, 20 national and international headache specialists recently conducted a Delphi consensus process to establish agreed-upon criteria for refractory migraine and highlight areas requiring further validation.

The Delphi process resulted in the establishment of 4 primary diagnostic criteria: refractory migraine, resistant migraine, probable refractory migraine, and migraine treatment responder. In alignment with the EHF’s 2020 framework, refractory migraine was defined as failure to respond to all categories of evidence-based therapies, whereas resistant migraine was defined as failure to respond to at least three categories. The probable refractory migraine criteria were introduced to address barriers to treatment access. Additionally, the migraine treatment responder criteria were created to standardize research comparisons between patients with refractory or resistant migraine and those who achieve meaningful improvement with treatment.

At the 2025 American Headache Society (AHS) Annual Meeting, held June 19-22 in Minneapolis, Minnesota, Jennifer Robblee, MD, MSc, headache neurologist at the Barrow Neurological Institute, presented these findings in session. During the meeting, Robblee sat down with NeurologyLive^® to discuss the potential impact of the 4 proposed diagnostic criteria. She explained how these criteria could support enrollment in studies and also aid clinical decision-making. Moreover, she noted that the criteria could help validate the disease burden in this patient population and may strengthen advocacy efforts for recognizing them as a distinct migraine subgroup. Although field testing in diverse clinical settings may still be needed, Robblee and colleagues recommended that the ICHD consider including these criteria in the appendix of its 4th edition.

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REFERENCES
1. Robblee J, Khan F, Marmura MJ. Reaching International Consensus on the Diagnosis of Refractory Migraine using a Delphi Consensus Process. Presented at: 2025 AHS Annual Meeting; June 19-22; Minneapolis, MN. OR-09.