• refractory migraine;
  • chronic migraine;
  • medication overuse headache;
  • wean;
  • multidisciplinary headache program;
  • neurostimulation

Many headache patients present when medications fail, are inadequate, are contraindicated, or are not tolerated. These are patients with severe disability. Most have daily headaches, including chronic migraine, trigeminal autonomic cephalalgias, or other primary headaches. This brief review addresses, in broad strokes, some thoughts about alternatives beyond the usual daily oral preventive therapies.

Do not proceed to more invasive or elaborate approaches until the big 3 are done: diagnosis is established, onabotulinumtoxinA administered when appropriate, that is, if the patient has chronic migraine, and wean is accomplished if the patient has medication overuse headache. Large numbers of patients are helped without the need for more arcane and unproven treatments by following these initial approaches. Simple nerve blocks can be useful in the initial steps, but more invasive blocks and stimulators are not recommended until the big 3 are completed.

Wean of overused medications must be absolute and may require an intravenous bridge over several days, either in an infusion unit or inpatient in a medical model. Wean should be accompanied by establishing onabotulinumtoxinA or daily prevention from the beginning.

Consider referral to a structured multidisciplinary headache program. This is for patients who require an interdisciplinary approach and may be day-hospital or inpatient.

Invasive blocks and stimulators may be appropriate, and the latter are currently being studied in controlled studies. The most promise, with the best balance of efficacy vs adverse event prospects, may be occipital nerve stimulators or sphenopalatine ganglion stimulators.