A refractory headache is one that shows a lack of response to usual, recommended treatments, but whether this includes a lack of response to acute, preventative, or both, types of medication is still debated. The importance of the need to identify and manage comorbidities in refractory headache patients cannot be overemphasized. Thus, in chronic migraine (CM), mainly, it is critical to recognize medication overuse as in many patients; this makes the individual’s headaches resistant to treatment. There are few effective treatment options for these, particularly for the latter.

Zagami AS reviewed the recent literature on the management of various refractory headaches, particularly CM, and medication overuse headache. There is no consent on the definitions of refractory CM and chronic cluster headache, although there is substantial agreement on some aspects of these terms. Several studies showed the importance of identifying medication overuse headache. There is yet no agreement on how to stop the medication overuse. Few studies recommend the use of preventative medication together with medication cessation. Latest reviews on neuromodulation have used both non-invasive as well as invasive techniques. As per the recent research, the non-invasive vagal nerve stimulation for CM has not shown positive outcomes; however, the data in chronic cluster headache still give hopes. Similar results were demonstrated by the latest studies on occipital nerve stimulation. In past years, new forms of neuromodulation have emerged, which mainly target the sphenopalatine ganglion in different types of headache. Sphenopalatine ganglion stimulation has shown supportive data for the therapy of chronic cluster headache. Data from the previous and new studies provided additional confirmation on the advantage of deep brain stimulation for refractory chronic cluster headache, although the exact point location is still disputed. A phase 3 trials in CM and cluster headache using CGRP monoclonal antibodies could be regarded as a new and effective treatment for our refractory headache patients.