Chronic migraine becomes “refractory” when preventive treatments don’t work to reduce the frequency of episodes. Treatment may include complementary therapies like neuromodulation.

Migraine can often be a debilitating condition, with symptoms lasting from 4 to 72 hours.

While many people find relief with various preventive medications (to reduce the frequency of episodes) and abortive treatments (to stop an episode in progress), sometimes, treatments aren’t enough.

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.

People with refractory migraine have 8 or moreTrusted Source migraine days per month for 6 months that don’t respond to treatment.

Refractory migraine is a risk factor for chronic migraine, which is when you have 15 or more headache days each month for at least 3 months, with 8 of them being migraine headaches.

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.

Refractory migraine vs. status migrainosus

Migraine episodes typically last 4 to 72 hoursTrusted Source. Sometimes, they can last longer, even if you try treating them. Status migrainosus is a condition in which migraine episodes persist for longer than 72 hours.

That’s different from refractory migraine, which refers to migraine as a condition, not an individual episode. People with refractory migraine are resistant to treatments and continue to have several episodes.

Experts do not universally agree on the criteria for diagnosing refractory migraine. But doctors commonly use the International Classification of Headache Disorders, 3rd edition (ICHD-3) 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:

  • Preventive 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 a doctor diagnoses 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.
  • Doctors have considered medication overuse headache (MOH): 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 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 roleTrusted Source.

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

  • anxiety
  • depression
  • insomnia
  • obstructive sleep apnea

Migraine can be 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

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 10 to 15 days per month. Over-the-counter drugs such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause MOH.

Overuse of triptans and opioid pain relievers like codeine can also cause MOH.

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.

Refractory migraine means that several traditional treatment options have already failed, so treatment can be challenging.

Treating refractory migraine often involves a multidisciplinary approach, involving some combination of the following:

  • Education: People with migraine can often identify specific factors that trigger an episode. Learning about your triggers and avoiding them may help reduce migraine frequency.
  • Behavioral therapy: Combining medication with techniques like cognitive behavioral therapy, biofeedback, or relaxation may be more beneficial than medication alone.
  • Medications: Taking multiple medications may help people with refractory migraine. For example, some researchersTrusted Source suggest dual therapy with Botox and anti-CGRP medications may be effective.
  • Neuromodulation: These techniquesTrusted Source involve sending electrical currents to your brain to alter nerve pathway activity.

A healthcare professional may also give you a migraine action planTrusted Source with steps to follow if a migraine episode starts.

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, an unbalanced 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). CBT may reduce the frequency of migraine episodes, according to a 2021 systematic review.

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 specific 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 your 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.

Refractory chronic migraine refers to migraine that is resistant to many forms of treatment. Doctors diagnose refractory chronic migraine if multiple treatments don’t help reduce the frequency of episodes or if you can’t take them because of side effects.

Because chronic refractory migraine causes more than 15 headache days each month, it 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 complementary 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.