. 2021 May 18;22(1):39.

doi: 10.1186/s10194-021-01252-4.

Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance

Simona Sacco^{1

2}, Christian Lampl³, Antoinette Maassen van den Brink⁴, Valeria Caponnetto^{5

6}, Mark Braschinsky⁷, Anne Ducros⁸, Patrick Little⁹, Patricia Pozo-Rosich^{10

11}, Uwe Reuter¹², Elena Ruiz de la Torre⁹, Margarita Sanchez Del Rio¹³, Alexandra J Sinclair^{14

15}, Paolo Martelletti^{16

17}, Zaza Katsarava^{18

19

20

21}; Burden and Attitude to Resistant and Refractory (BARR) Study Group

Collaborators, Affiliations

Collaborators

Burden and Attitude to Resistant and Refractory (BARR) Study Group:
Genci Cakciri, Pavllo Djamandi, Serla Grabova, Gleni Halili, Jera Kruja, Altin Kuqo, Diana Naco, Aida Quka, Ladjola Stefanidhi, Gentian Vyshka, Ilirjana Zekja, Osvaldo Bruera, Dilver Gómez, Brenda Guitian, Juan Carlos Roma, Ike Leon Chen, Christian Lampl, Samira Bashirova, Maxim Linkov, Daan Van Den Abbeele, Geraldine Vanderschueren, Roberta Araujo, Renato Arruda, Antônio Catharino, Jovana Ciriaco, Amauri Dalla Corte, Ricardo Dornas, Bernardo Felsenfeld Jr, André Fonseca Taufner, Yara Fragoso, Rubens Hurtado, Daniel Isoni Martins, Renata Londero, Luciano Melo, Kelton Stivenson Mignoni, Paulo Victor Sgobbi De Souza, Marcio Nattan Souza, Sevdzhan Osman, Veronika Baltzer, Luis Fabian Pacheco Mosquera, Ivan Dubroja, Zlatko Hucika, Marijana Lisak, Arijana Lovrencic-Huzjan, Ivo Lušić, Darija Mahovic Lakusic, Petr Mikulenka, Pavel Řehulka, Faisal Mohammad Amin, Sonja Antic, Zainab Fakhril-Din, Jakob Moeller-Hansen, Signe Munksgaard, Ana Maria Nan, Lanfranco Pellesi, Henrik Schytz, Manuel Vides, Kati Braschinsky, Mark Braschinsky, Ülle Krikmann, Anne Ducros, Caroline Roos, Alexandre Cauchie, Lucas Christian, Evelyne Guégan-Massardier, Genevieve Demarquay, Geraud Gilles, Jerome Mawet, Emmanuelle Kuhn, Michel Lanteri Minet, Mihaela Bustuchina Vlaicu, Xavier Moisset, Mirela Muresan, Mitra Najjar-Ravan, Pierric Giraud, Sabine Simonin, Solène De Gaalon, George Chakhava, Miranda Demuria, George Gegelashvili, Nana Kapanadze, Angela Antonakakis, Charly Gaul, Stefanie Förderreuther, Jana-Isabel Huhn, Sardor Ibragimov, Katharina Kamm, Bianca Raffaelli, Reiner Czaniera, Ruth Ruscheweyh, Uwe Reuter, Evangelia Gavanozi, Georgios Karagiorgis, Theodoros Mavridism, Csaba Ertsey, Dubey Shubham, Antonia Dewi Callista Tanowi, Stefanus Erdana Putra, Deby Wahyuning Hadi, Leny Kurnia, Musadir Nasrul, Maria Albanese, Fabio Antonaci, Gian Maria Asioli, Roberta Baschi, Enrico Bentivegna, Nicoletta Brunelli, Salvatore Caratozzolo, Teresa Catarci, Alessandra Cherchi, Ilenia Corbelli, Alfredo Costa, Ciro De Luca, Alberto Doretti, Valentina Favoni, Natascia Ghiotto, Maria Adele Giamberardino, Luca Giani, Giorgio Zanchin, Flora Govone, Giovanni Grillo, Edoardo Mampreso, Paolo Martelletti, Andrea Negro, Raffaele Ornello, Marcello Pasculli, Umberto Pensato, Maria Pia Addolorata Prudenzano, Simone Quintana, Rosaria Rapisarda, Michele Romoli, Antonio Russo, Marco Russo, Simona Sacco, Valerio Spuntarelli, Cindy Tiseo, Angelo Torrente, Alessandro Vacca, Giovanna Vaula, Alessandro Viganò, Simone Vigneri, Aija Freimane, Evita Slosberga, Linda Zvaune, Hui Jan Tan, Cherilyn Fenech, Rafael Cobilt-Catana, Yazmín De La Garza Neme, Marco Martínez, Jefferson Voltaire Proaño Narvaez, Andrea Rodriguez Herrera, Damaris Vazquez, Oxana Grosu, Adi Jakupi, Espen Saxhaug Kristoffersen, Erling Tronvik, Bendik S Winsvold, Mehboob Azhar, Maria Teresa Reyes Alvarez, Leidi Vilchez Fernandez, Greg David Dayrit, Ewa Katarzyna Czapinska-Ciepiela, Michal Fila, Anna Gryglas-Dworak, Marina Couto, Paula Esperança, Axel Ferreira, Raquel Gil-Gouveia, Ana Goncalves, Margarida Lopes, Miguel Lourenço, Jorge Machado, Manuel Marinho, Miguel Angelo Miranda, Filipe Palavra, Elsa Parreira, Isabel Pavao Martins, Liliana Pereira, José Maria Pereira Monteiro, Pavel Leahu, Stefan Aloman, Ekaterina Abramova, Leila Akhmadeeva, Anastasia Belopasova, Inna Bogdanova, Mariya Chernyak, Miss Epifanova, Elena Fedorova, Anton Felbush, Maria Karpova, Daria Korobkova, Daria Korotkova, Nina Latysheva, Tatiana Makeeva, Kristina Mikhalkina, Vera Osipova, Olga Roshchina, Anna Serga, O V Serousova, Yulia Sidorova, Iaroslav Skiba, Kirill Skorobogatykh, Nina Vashchenko, Slobodan Apostolski, Nevenka Buder, Aleksandar Kopitovic, Jovanovic Mirjana, Ana Podgorac, Dejan Rakic, Svetlana Simić, Martinovic Zarko, Jasna Zidverc Trajkovic, Isabel Beltran-Blasco, María Dolores Calabria Gallego, Samuel Díaz Insa, David Ezpeleta, María Fernández, David García-Azorín, Nuria González-García, Angel L Guerrero, Edelmira Guillamon, Jaime Herreros Rodriguez, Almudena Layos-Romero, Vicente Medrano, Ane Mínguez-Olaondo, Santiago Navarro Muñoz, Martí Paré Curell, Patricia Pozo-Rosich, Marta Ruibal, Jose Maria Sanchez Alvarez, Margarita Sanchez Del Rio, Sonia Santos, Rafael Soler, Javier Viguera, Ramon Zabalza, Tagwa Abdelrahman, Salih Boushra Abobaker Hamza, Mohammed Nasir Mustafa, Lars Edvinsson, Andreas Gantenbein, Isabella Maraffi, Emile Couturier, Thijs Dirkx, Michel Hoebert, Wpj Van Oosterhout, Mulleners Wim, Rachel Zwartbol, Mesut Bakır, Hatice Demirel, Ali Kemal Erdemoglu, Devrimsel H Ertem, Sinan Gönüllü, Elif Ilgaz Aydinlar, Levent Ertuğrul Inan, Berkay Ölmez, Taner Ozbenli, Aynur Özge, Derya Uluduz, Tugba Uyar Cankay, Pinar Yalinay Dikmen, Amrit Bhushan Saxena, Myroslav Bozhenko, Nataliya Bozhenko, Rostyslav Bubnov, Olena Tsurkalenko, Ishaq Abu-Arafeh, Luis Idrovo, Sarah Miller, Niranjanan Nirmalananthan, Alexandra Sinclair, Esteban Taleti, Alex Valori, William Whitehouse, Adam Zermansky, Myat Thura

Affiliations

¹ Neuroscience section - Department of Biotechnological and Applied Clinical Sciences and (Edificio Coppito 2), University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy. simona.sacco@univaq.it.
² Regional Referral Headache Center of the Abruzzo Region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy. simona.sacco@univaq.it.
³ Department of Neurology, Headache Medical Centre Linz, Hospital Barmherzige Brüder, Centre of Integrative Medicine (ZiAM) Ordensklinikum Linz, Linz, Austria.
⁴ Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁵ Neuroscience section - Department of Biotechnological and Applied Clinical Sciences and (Edificio Coppito 2), University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy.
⁶ Regional Referral Headache Center of the Abruzzo Region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy.
⁷ Headache Clinic, Department of Neurology, Tartu University Clinics, Tartu, Estonia.
⁸ Headache Unit, Neurology Department, Montpellier University Hospital and Montpellier University, Montpellier, France.
⁹ European Migraine & Headache Alliance (EMHA), Brussels, Belgium.
¹⁰ Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.
¹¹ Headache and Neurological Pain Research Group, Department de Medicina, Universitat Autònoma de Barcelona, Vall d'Hebron Research Institute, Barcelona, Spain.
¹² Charité Universitätsmedizin Berlin, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹³ Neurology Department, Clinica Universidad de Navarra, Madrid, Spain.
¹⁴ Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
¹⁵ Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
¹⁶ Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
¹⁷ Regional Referral Headache Center of the Lazio Region, Sant'Andrea Hospital, Rome, Italy.
¹⁸ Christian Hospital, Unna, Germany.
¹⁹ Department of Neurology, University of Duisburg-Essen, Essen, Germany.
²⁰ EVEX Medical Corporation, Tbilisi, Georgia.
²¹ IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.

PMID: 34006218
PMCID: PMC8130435
DOI: 10.1186/s10194-021-01252-4

Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance

Simona Sacco et al. J Headache Pain. 2021.

. 2021 May 18;22(1):39.

doi: 10.1186/s10194-021-01252-4.

Authors

Collaborators

Burden and Attitude to Resistant and Refractory (BARR) Study Group:
Genci Cakciri, Pavllo Djamandi, Serla Grabova, Gleni Halili, Jera Kruja, Altin Kuqo, Diana Naco, Aida Quka, Ladjola Stefanidhi, Gentian Vyshka, Ilirjana Zekja, Osvaldo Bruera, Dilver Gómez, Brenda Guitian, Juan Carlos Roma, Ike Leon Chen, Christian Lampl, Samira Bashirova, Maxim Linkov, Daan Van Den Abbeele, Geraldine Vanderschueren, Roberta Araujo, Renato Arruda, Antônio Catharino, Jovana Ciriaco, Amauri Dalla Corte, Ricardo Dornas, Bernardo Felsenfeld Jr, André Fonseca Taufner, Yara Fragoso, Rubens Hurtado, Daniel Isoni Martins, Renata Londero, Luciano Melo, Kelton Stivenson Mignoni, Paulo Victor Sgobbi De Souza, Marcio Nattan Souza, Sevdzhan Osman, Veronika Baltzer, Luis Fabian Pacheco Mosquera, Ivan Dubroja, Zlatko Hucika, Marijana Lisak, Arijana Lovrencic-Huzjan, Ivo Lušić, Darija Mahovic Lakusic, Petr Mikulenka, Pavel Řehulka, Faisal Mohammad Amin, Sonja Antic, Zainab Fakhril-Din, Jakob Moeller-Hansen, Signe Munksgaard, Ana Maria Nan, Lanfranco Pellesi, Henrik Schytz, Manuel Vides, Kati Braschinsky, Mark Braschinsky, Ülle Krikmann, Anne Ducros, Caroline Roos, Alexandre Cauchie, Lucas Christian, Evelyne Guégan-Massardier, Genevieve Demarquay, Geraud Gilles, Jerome Mawet, Emmanuelle Kuhn, Michel Lanteri Minet, Mihaela Bustuchina Vlaicu, Xavier Moisset, Mirela Muresan, Mitra Najjar-Ravan, Pierric Giraud, Sabine Simonin, Solène De Gaalon, George Chakhava, Miranda Demuria, George Gegelashvili, Nana Kapanadze, Angela Antonakakis, Charly Gaul, Stefanie Förderreuther, Jana-Isabel Huhn, Sardor Ibragimov, Katharina Kamm, Bianca Raffaelli, Reiner Czaniera, Ruth Ruscheweyh, Uwe Reuter, Evangelia Gavanozi, Georgios Karagiorgis, Theodoros Mavridism, Csaba Ertsey, Dubey Shubham, Antonia Dewi Callista Tanowi, Stefanus Erdana Putra, Deby Wahyuning Hadi, Leny Kurnia, Musadir Nasrul, Maria Albanese, Fabio Antonaci, Gian Maria Asioli, Roberta Baschi, Enrico Bentivegna, Nicoletta Brunelli, Salvatore Caratozzolo, Teresa Catarci, Alessandra Cherchi, Ilenia Corbelli, Alfredo Costa, Ciro De Luca, Alberto Doretti, Valentina Favoni, Natascia Ghiotto, Maria Adele Giamberardino, Luca Giani, Giorgio Zanchin, Flora Govone, Giovanni Grillo, Edoardo Mampreso, Paolo Martelletti, Andrea Negro, Raffaele Ornello, Marcello Pasculli, Umberto Pensato, Maria Pia Addolorata Prudenzano, Simone Quintana, Rosaria Rapisarda, Michele Romoli, Antonio Russo, Marco Russo, Simona Sacco, Valerio Spuntarelli, Cindy Tiseo, Angelo Torrente, Alessandro Vacca, Giovanna Vaula, Alessandro Viganò, Simone Vigneri, Aija Freimane, Evita Slosberga, Linda Zvaune, Hui Jan Tan, Cherilyn Fenech, Rafael Cobilt-Catana, Yazmín De La Garza Neme, Marco Martínez, Jefferson Voltaire Proaño Narvaez, Andrea Rodriguez Herrera, Damaris Vazquez, Oxana Grosu, Adi Jakupi, Espen Saxhaug Kristoffersen, Erling Tronvik, Bendik S Winsvold, Mehboob Azhar, Maria Teresa Reyes Alvarez, Leidi Vilchez Fernandez, Greg David Dayrit, Ewa Katarzyna Czapinska-Ciepiela, Michal Fila, Anna Gryglas-Dworak, Marina Couto, Paula Esperança, Axel Ferreira, Raquel Gil-Gouveia, Ana Goncalves, Margarida Lopes, Miguel Lourenço, Jorge Machado, Manuel Marinho, Miguel Angelo Miranda, Filipe Palavra, Elsa Parreira, Isabel Pavao Martins, Liliana Pereira, José Maria Pereira Monteiro, Pavel Leahu, Stefan Aloman, Ekaterina Abramova, Leila Akhmadeeva, Anastasia Belopasova, Inna Bogdanova, Mariya Chernyak, Miss Epifanova, Elena Fedorova, Anton Felbush, Maria Karpova, Daria Korobkova, Daria Korotkova, Nina Latysheva, Tatiana Makeeva, Kristina Mikhalkina, Vera Osipova, Olga Roshchina, Anna Serga, O V Serousova, Yulia Sidorova, Iaroslav Skiba, Kirill Skorobogatykh, Nina Vashchenko, Slobodan Apostolski, Nevenka Buder, Aleksandar Kopitovic, Jovanovic Mirjana, Ana Podgorac, Dejan Rakic, Svetlana Simić, Martinovic Zarko, Jasna Zidverc Trajkovic, Isabel Beltran-Blasco, María Dolores Calabria Gallego, Samuel Díaz Insa, David Ezpeleta, María Fernández, David García-Azorín, Nuria González-García, Angel L Guerrero, Edelmira Guillamon, Jaime Herreros Rodriguez, Almudena Layos-Romero, Vicente Medrano, Ane Mínguez-Olaondo, Santiago Navarro Muñoz, Martí Paré Curell, Patricia Pozo-Rosich, Marta Ruibal, Jose Maria Sanchez Alvarez, Margarita Sanchez Del Rio, Sonia Santos, Rafael Soler, Javier Viguera, Ramon Zabalza, Tagwa Abdelrahman, Salih Boushra Abobaker Hamza, Mohammed Nasir Mustafa, Lars Edvinsson, Andreas Gantenbein, Isabella Maraffi, Emile Couturier, Thijs Dirkx, Michel Hoebert, Wpj Van Oosterhout, Mulleners Wim, Rachel Zwartbol, Mesut Bakır, Hatice Demirel, Ali Kemal Erdemoglu, Devrimsel H Ertem, Sinan Gönüllü, Elif Ilgaz Aydinlar, Levent Ertuğrul Inan, Berkay Ölmez, Taner Ozbenli, Aynur Özge, Derya Uluduz, Tugba Uyar Cankay, Pinar Yalinay Dikmen, Amrit Bhushan Saxena, Myroslav Bozhenko, Nataliya Bozhenko, Rostyslav Bubnov, Olena Tsurkalenko, Ishaq Abu-Arafeh, Luis Idrovo, Sarah Miller, Niranjanan Nirmalananthan, Alexandra Sinclair, Esteban Taleti, Alex Valori, William Whitehouse, Adam Zermansky, Myat Thura

Affiliations

¹ Neuroscience section - Department of Biotechnological and Applied Clinical Sciences and (Edificio Coppito 2), University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy. simona.sacco@univaq.it.
² Regional Referral Headache Center of the Abruzzo Region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy. simona.sacco@univaq.it.
³ Department of Neurology, Headache Medical Centre Linz, Hospital Barmherzige Brüder, Centre of Integrative Medicine (ZiAM) Ordensklinikum Linz, Linz, Austria.
⁴ Division of Pharmacology, Department of Internal Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
⁵ Neuroscience section - Department of Biotechnological and Applied Clinical Sciences and (Edificio Coppito 2), University of L'Aquila, Via Vetoio, 67100, L'Aquila, Italy.
⁶ Regional Referral Headache Center of the Abruzzo Region, ASL Avezzano-Sulmona-L'Aquila, L'Aquila, Italy.
⁷ Headache Clinic, Department of Neurology, Tartu University Clinics, Tartu, Estonia.
⁸ Headache Unit, Neurology Department, Montpellier University Hospital and Montpellier University, Montpellier, France.
⁹ European Migraine & Headache Alliance (EMHA), Brussels, Belgium.
¹⁰ Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.
¹¹ Headache and Neurological Pain Research Group, Department de Medicina, Universitat Autònoma de Barcelona, Vall d'Hebron Research Institute, Barcelona, Spain.
¹² Charité Universitätsmedizin Berlin, Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany.
¹³ Neurology Department, Clinica Universidad de Navarra, Madrid, Spain.
¹⁴ Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
¹⁵ Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
¹⁶ Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy.
¹⁷ Regional Referral Headache Center of the Lazio Region, Sant'Andrea Hospital, Rome, Italy.
¹⁸ Christian Hospital, Unna, Germany.
¹⁹ Department of Neurology, University of Duisburg-Essen, Essen, Germany.
²⁰ EVEX Medical Corporation, Tbilisi, Georgia.
²¹ IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation.

PMID: 34006218
PMCID: PMC8130435
DOI: 10.1186/s10194-021-01252-4

Abstract

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.

Keywords: Migraine; Migraine care; Refractory migraine; Resistant migraine.

PubMed Disclaimer

Conflict of interest statement

Mark Braschinsky: Fees as a speaker or for participation to advisory boards from Abbott Laboratories, Allergan Inc., Berlin-Chemie AG (Menarini Group), Boehringer Ingelheim Pharma GmbH, Desitin Arzneimittel GmbH, EV3, Gedeon Richter Ltd., GlaxoSmithKline, KBM Pharma Ltd., H. Lundbeck A/S, Novartis Pharma Services Inc., Nycomed SEFA, Orion Pharma, Pfizer Inc., Sanofi-Aventis, Sandoz d.d., Scanmed Group, Solvay Pharmaceuticals, Teva Pharmaceutical Industries Ltd./Sicor Biotech UAB, Zentiva International. Previously consultant for H. AbbePharma GmbH, Merz Pharmaceuticals.

Anne Ducros: Fees as speaker or participation to advisory boards from Eli-Lilly, Novartis, Teva.

Zaza Katsarava: Fees as speaker or participation to advisory boards from Novartis, Lilly, TEVA, Allergan, Merck and Daiichi.

Christian Lampl: Fees as speaker or for participation to advisory boards from Allergan, Eli-Lilly, Novartis, Pfizer, Teva.

Patrick Little: none.

Paolo Martelletti: Fees as speaker or for participation to advisory boards from Allergan, Eli-Lilly, Novartis, Teva.

Antoinette Massen van den Brink: Research grant and/or speaker/consultant fees from Amgen/Novartis, Eli-Lilly, Teva.

Patricia Pozo-Rosich: Fees as consultant and speaker for Allergan, Almirall, Biohaven, Chiesi, The Corpus, Eli Lilly, Medscape, Neurodiem, Novartis and Teva. Research funding from, AGAUR, ERANet Neuron, FEDER RISC3CAT, la Caixa foundation, Instituto Investigación Carlos III, MICINN, Migraine Research Foundation, Novartis, PERIS; funding for clinical trials from Alder, Allergan/AbbVie, Electrocore, Eli Lilly, Lundbeck, Novartis and Teva.

Uwe Reuter: Fees as consultant and speaker for Allergan, Biohaven, The Corpus, Eli Lilly, Medscape, Novartis, STREAMedUP and Teva. Research funding from BMBF and Novartis, Institutional funding for clinical trials from Alder, Amgen. Allergan, Eli Lilly, Novartis and Teva.

Elena Ruiz de la Torre: none.

Simona Sacco: Fees as speaker or for participation to advisory boards from Abbott, Allergan, AstraZeneca, Eli-Lilly, Medscape, Novartis, Teva.

Margarita Sanchez Del Rio: Fees as speaker or for participation to advisory boards from Allergan, Eli-Lilly, Novartis, Teva.

Alexandra J Sinclair: Fees as speaker from Novartis and Allergan.

Valeria Caponnetto: Fees as member of Advisory Board from Novartis.

Figures

**Fig. 1**
Distribution by country of participating physicians

**Fig. 2**
Response to the question “How often do you see in your practice patients with resistant/refractory migraine?”

**Fig. 3**
Low, moderate or high confidence in managing resistant and refractory migraine according to characteristics of headache care and physicians

**Fig. 4**
Response to the question “Where are patients with resistant/refractory treated?”

**Fig. 5**
Response to the question “Where should patients with resistant/refractory migraine be managed?”

See this image and copyright information in PMC

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Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance

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Burden and attitude to resistant and refractory migraine: a survey from the European Headache Federation with the endorsement of the European Migraine & Headache Alliance

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