Refractory migraine profile in CGRP‐monoclonal antibodies scenario

Abstract

Objective

Refractory migraine (RefM) represents a conundrum that headache experts have to face with. We aim to investigate whether a peculiar profile may characterize patients with RefM according to 2020 European Headache Federation criteria. Furthermore, to substantiate a dysfunctional dopaminergic pathway involvement in these patients, we explored the effectiveness of olanzapine.

Materials & Methods

Eighty-four patients (fitting previous RefM criteria of the 2014) were treated with erenumab for six months. Differences between clinical and demographic features of responder (RefM according to 2014 criteria) and not-responder (RefM according to 2020 criteria) patients to CGRP-mAbs were investigated and their predictive values assessed. In fifteen patients with RefM not responders to CGRP-mAbs, olanzapine was administered (5 mg/die) for 3 months and frequency and pain intensity of migraine attacks were estimated.

Results

Patients with RefM not responsive to CGRP-mAbs (29/84) when compared with RefM responsive to CGRP-mAbs showed higher baseline frequency of migraine attacks, medication overuse and pain catastrophizing scale (PCS) scores. Logistic regression analyses showed that frequency of attacks, medication overuse and PCS score represent independent negative predictors of CGRP-mAbs response. A ≥50% reduction of headache days/month was observed after olanzapine treatment in 67% of patients with RefM not responsive to CGRP-mAbs.

Conclusions

We outline that higher frequency of migraine attacks, medication overuse and pain catastrophizing characterize patients with RefM not responsive to CGRP-mAbs. In this frame, olanzapine effectiveness on frequency and pain intensity of migraine attacks supports the hypothesis that migraine refractoriness may be subtended by a prominent involvement of the dopaminergic pathway.

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