Having a migraine headache for any length of time can be debilitating. It’s a good thing that most of these intensely painful headaches resolve in less than 24 hours. But what about when treatment doesn’t work and your migraine persists for several days, not hours?

Refractory migraine, also called intractable migraine, refers to migraine that is resistant to multiple kinds of typical treatments. That’s what the word “refractory” means in this context. This type of migraine can be chronic if you have 8 or more of these migraine days per month.

In many cases, people with refractory chronic migraine experience status migrainosus, an episode that lasts longer than 72 hours.

Refractory chronic migraine can be a highly disabling condition. Here’s what you need to know about what causes it and how to manage it.

Experts do not universally agree on the criteria for diagnosing refractory migraine. But the International Classification of Headache Disorders, 3rd edition (ICHD-3) is commonly used by doctors when trying to distinguish refractory migraine from other types of migraine. The ICHD-3 is a diagnostic manual for the treatment of migraine.

According to the ICHD-3, it can even be difficult to distinguish chronic migraine from episodic migraine since continuous headaches aren’t easily distinguishable from one day to the next. In general, though, the ICHD-3 uses the term “chronic” when a person has 15 or more headache days per month, with 8 of them confirmed as migraine.

Despite the differing criteria, a 2019 review outlines several things doctors can look for when trying to diagnose refractory chronic migraine based on ICHD guidelines:

  • Preventative treatments have failed. Several preventive treatments aim to reduce your number of migraine episodes. There’s no consensus on how many of these treatments need to fail before you can be diagnosed with refractory migraine, but the range seems to be between two and five. In this case, “failure” can mean two things: the drug doesn’t reduce your migraine frequency or severity, or you can’t tolerate the drug because of side effects.
  • Alternative therapies have failed. If you’ve tried things like acupuncture or biofeedback to reduce your migraine and it hasn’t helped, this also informs your diagnosis.
  • Medication overuse headache (MOH) has been considered. Some people with chronic migraine take pain relief medication almost daily to function. But this can cause withdrawal symptoms, including headache, when the medication wears off, or they stop taking it. Some experts think doctors should treat MOH and rule it out as a source of the migraine before diagnosing refractory migraine, while others disagree.

No one knows for certain what causes some people to experience migraine, but genetics, hormones, and serotonin levels may play a role.

Several mental health conditions often occur with chronic migraine and may be a cause. These include:

  • anxiety
  • depression
  • insomnia
  • obstructive sleep apnea

As mentioned before, some doctors consider medication overuse to be a cause of refractory migraine, while others consider it separately.

MOH is common in people with migraine conditions, especially if they take pain relief medications more than 2 or 3 days per week. Over-the-counter drugs such as acetaminophen and NSAIDs can cause MOH. Overuse of triptans and opioid pain relievers like codeine can also cause MOH.

Migraine is often a progressive disorder. That means people usually start out with occasional episodes. Over time, they become more frequent, severe, or even chronic. This may also be true for refractory migraine.

According to a 2019 review, risk factors for progression include:

  • obesity
  • caffeine
  • medication overuse
  • sleep problems

The symptoms of refractory migraine are generally the same as other types of migraine and may include:

  • throbbing, stabbing, or intense pain, either on one side of your head or both
  • sensitivity to light, noise, or smell
  • nausea and vomiting
  • aura, a visual or sensory disturbance that happens right before an attack

Note that some people have migraine with aura and others don’t.

What makes refractory chronic migraine unique is that symptoms are resistant to several lines of treatment. Next, we’ll review what treatment options might provide relief.

Refractory migraine means that several traditional treatment options have already failed. Treating this condition can be difficult.

Your healthcare professional should give you a migraine action plan with steps to follow if a migraine episode starts. Some of the steps may include at-home care. But many people with refractory migraine require treatment at a hospital, either in the emergency department or as an inpatient, so that they can access medications not available as prescriptions for home use.

If you’re experiencing refractory migraine, here are some possible treatments:

  • Intravenous (IV) pain relievers. Medications delivered through an IV work faster and are better absorbed. A care team in a hospital may administer an NSAID like ketorolac (Toradol) through an IV to give you more effective migraine pain relief.
  • Corticosteroids. Doctors typically prescribe methylprednisolone in-hospital to disrupt an intractable migraine. It’s also sometimes used to break the pattern of MOH.
  • Intranasal drugs. Some drugs can relieve acute and refractory migraine episodes when you administer them via nasal spray, such as ketamine and lidocaine.
  • Magnesium. Magnesium sulfate is also commonly given at hospitals via IV for intractable migraine and may alleviate some of your more intense symptoms.

Additionally, your doctor may offer medications to help relieve some of your other, non-pain-related symptoms:

  • Saline. Dehydration can worsen migraine symptoms, so most hospitals will want to rehydrate you. This won’t cure your migraine, but it may help you feel better in other ways.
  • Anti-nausea drugs. People with refractory migraine commonly feel nauseated and have trouble eating or keeping down food. Doctors commonly give anti-nausea and anti-vomiting drugs in these cases.

In a hospital setting, doctors may combine several of these strategies to help reduce your migraine symptoms quickly and break the cycle of refractory chronic migraine.

Unfortunately, there’s no cure for migraine, including refractory chronic migraine. Management of the condition means trying to reduce your number of migraine days by:

  • avoiding your triggers
  • seeking out alternative therapies
  • making certain lifestyle changes

Address coexisting conditions

Physical and mental health conditions can make migraine symptoms worse or more frequent. Taking care to manage any other conditions you have may reduce your number of disabling days by addressing some of the root causes of your migraine.

Keep a migraine diary

Migraine experts may tell you to identify and avoid your migraine triggers in order to have fewer migraine days. But you can’t do that unless you find a way to keep track of your headaches and look for patterns. Keeping a migraine diary can help you pinpoint your triggers and, in some cases, avoid them to limit your migraine days.

Take care of your physical health

According to a 2019 study, sleep and headaches are closely intertwined. It’s important to stick to a regular sleep schedule if you can.

Similarly, poor diet, stress, lack of exercise, and lack of hydration can all increase your risk of a migraine episode. Focusing on taking care of your body can improve your migraine health, too.

Consider therapy

You may want to see a mental health professional trained in cognitive behavioral therapy (CBT). According to a 2015 study, CBT has been linked to an improvement in migraine symptoms.

CBT may also help you develop coping tools for living with this condition and strategies for communicating with others about it.

Try alternative therapies

Some people find relief with alternative therapies, including:

It’s best to use these strategies in conjunction with more standard treatments and under the supervision of a doctor.

None of these management techniques replaces seeing a healthcare professional who is knowledgeable about refractory chronic migraine. You’ll likely need medical intervention from time to time to treat your symptoms. You’ll want to have a good relationship with a doctor who can help you improve your quality of life as much as possible.

Is refractory chronic migraine considered a disability?

Migraine headaches that aren’t caused by any other underlying condition fall under the category of primary headache disorders. You may be able to apply for short- or long-term disability through your employer for your migraine. The Social Security Administration will consider disability claims related to all forms of migraine, including refractory chronic migraine, if the claims meet certain criteria.

Typically, the migraine condition has to:

  • significantly limit your ability to work for an extended period
  • be confirmed by a doctor
  • be resistant to several forms of treatment

To apply for disability, you’ll need to collect evidence of work history, your medical history, and other documentation related to your migraine condition. The process can take a long time. Here’s how to get started.

Was this helpful?

Refractory chronic migraine is any migraine episode that is resistant to many forms of treatment. It can often last for several days. Medication overuse headaches are a common cause of this type of migraine, but there are other risk factors.

This type of migraine can be disabling and hugely disruptive to daily life. It’s important to work with a doctor who understands it well. They can help you make a migraine action plan and advise you on alternative treatments or strategies to reduce your number of migraine days.

Refractory chronic migraine can be a frustrating and isolating condition that’s tough to go through alone. You may consider therapy or joining a migraine support group. They can provide you with helpful advice and coping strategies.