Reuter, U. (Uwe)
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- European headache federation consensus on the definition of resistant and refractory migraine(2020) Pozo-Rosich, P. (Patricia); Ducros, A. (Anne); Martelletti, P. (Paolo); Reuter, U. (Uwe); Sinclair, A. (Alexandra); Ruiz-de-la-Torre, E. (Elena); Lampl, C. (Christian); Sacco, S. (Simona); Katsarava, Z. (Zaza); Braschinsky, M. (Mark); Sanchez-del-Río, M. (Margarita); Little, P. (Patrick); Maassen-van-den-Brink, A. (Antoinette)Introduction: Despite advances in the management of headache disorders, some patients with migraine do not experience 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 create 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 debilitating 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 available preventatives and suffer from at least 8 debilitating headache days per month for at least 6 consecutive months. Drug failure may include lack of efficacy or lack of tolerability. Debilitating headache 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, progresses 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 stimulate further clinical, scientific and social attention to patients who suffer from migraine which is difficult-to-treat.
- Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance(Springer Nature, 2021) Sacco, S. (Simona); Lampl, C. (Christian); Maassen-van-den-Brink, A. (Antoinette); Caponnetto, V. (Valeria); Braschinsky, M. (Mark); Ducros, A. (Anne); Little, P. (Patrick); Pozo-Rosich, P. (Patricia); Reuter, U. (Uwe); Ruiz-de-la-Torre, E. (Elena); Sanchez-del-Río, M. (Margarita); Sinclair, A. (Alexandra); Martelletti, P. (Paolo); Katsarava, Z. (Zaza)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.
- Diagnosis and management of migraine in ten steps(Springer Nature, 2021) Eigenbrodt, A.K. (Anna K.); Ashina, H. (Håkan); Khan, S. (Sabrina); Diener, H.C. (Hans Christoph); Mitsikostas, D. (Dimos); Sinclair, A. (Alexandra); Pozo-Rosich, P. (Patricia); Martelletti, P. (Paolo); Ducros, A. (Anne); Braschinsky, M. (Mark); Sanchez-del-Río, M. (Margarita); Daniel, O. (Oved); Özge, A. (Aynur); Mammadbayli, A. (Ayten); Arons, M. (Mihails); Skorobogatykh, K. (Kirill); Romanenko, V. (Vladimir); Terwindt, G.M. (Gisela M.); Paemeleire, K. (Koen); Sacco, S. (Simona); Reuter, U. (Uwe); Lampl, C. (Christian); Schytz, H.W. (Henrik W.); Katsarava, Z. (Zaza); Steiner, T.J. (Timothy J.); Ashina, M. (Messoud)Migraine is a disabling primary headache disorder that directly affects more than one billion people worldwide. Despite its widespread prevalence, migraine remains under-diagnosed and under-treated. To support clinical decision-making, we convened a European panel of experts to develop a ten-step approach to the diagnosis and management of migraine. Each step was established by expert consensus and supported by a review of current literature, and the Consensus Statement is endorsed by the European Headache Federation and the European Academy of Neurology. In this Consensus Statement, we introduce typical clinical features, diagnostic criteria and differential diagnoses of migraine. We then emphasize the value of patient centricity and patient education to ensure treatment adherence and satisfaction with care provision. Further, we outline best practices for acute and preventive treatment of migraine in various patient populations, including adults, children and adolescents, pregnant and breastfeeding women, and older people. In addition, we provide recommendations for evaluating treatment response and managing treatment failure. Lastly, we discuss the management of complications and comorbidities as well as the importance of planning long-term follow-up.