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Refractory Chronic Migraine — RACP Adult Medicine MCQ

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HardNeurologyRefractory Chronic MigraineRACP Adult Medicine

A 35-year-old woman with chronic migraine (18 headache days/month) has failed adequate trials of propranolol, topiramate, and amitriptyline. She has medication-overuse headache from codeine. She meets criteria for chronic migraine. What is the most appropriate next step?

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Correct answer: BCGRP monoclonal antibody (erenumab)

Chronic migraine (≥15 headache days/month, ≥8 with migraine features) refractory to ≥3 standard preventers is an indication for CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) per PBS criteria in Australia. The medication-overuse headache (from codeine) must also be addressed with withdrawal and patient education. Opioids should be ceased.

Reference: eTG Neurology – 2024 – Migraine; Headache Australia 2024; PBS