PO-46 | Diagnostic tests and headache misdiagnoses in individuals with resistant and refractory migraine – data from the REFINE study

Federico De Santis,¹ Chiara Rosignoli,¹ Agnese Onofri,¹ Mark Braschinsky,² Olga Sved,² Raquel Gil-Gouveia,^3,4 Renato Oliveira,³ Christian Lampl,⁵ Jakob Paungarttner,⁵ Paolo Martelletti,⁶ William David Wells-Gatnik,⁷ Isabel Pavao Martins,⁸ Dimos D Mitsikostas,⁹ Loukia Apostolakopoulou,⁹ Aynur Ozge,¹⁰ Dilan Bayar Narin,¹⁰ Patricia Pozo-Rosich,¹¹ Albert Munoz-Vendrell,¹¹ Maria Pia Prudenzano,¹² Martino Gentile,¹² Kristina Ryliskiene,¹³ Jurgita Vainauskiene,¹⁴ Margarita Sanchez-del-Rio,¹⁵ Fabrizio Vernieri,¹⁶ Gianmarco Iaccarino,¹⁶ Marta Waliszewska-Prosół,¹⁷ Sławomir Budrewicz,¹⁷ Marta Carnovali,¹⁸ Zaza Katsarava,¹⁸ Simona Sacco,¹ Raffaele Ornello¹ | ¹Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy; ²Department of Neurology and Neurosurgery, Institute of Clinical Medicine, Faculty of Medicine, University of Tartu and Neurology Clinic of Tartu University Hospital, Tartu, Estonia; ³Headache Center, Neurology Department, Hospital da Luz, Lisboa, Portugal; ⁴Center for Interdisciplinary Research in Health, Universidade Católica Portuguesa, Lisboa; ⁵Headache Medical Center, Seilerstaette Linz, Linz, Austria; ⁶Unitelma Sapienza University of Rome, Italy; ⁷Texas Tech University Health Sciences Center, El Paso TX, USA; ⁸Centro de Estudos Egas Moniz, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; ⁹First Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece; ¹⁰Department of Neurology, Mersin University Medical Faculty, Mersin, Turkey and NOROM Neuroscience and Neurotechnology Center of Excellence, Ankara, Turkey; ¹¹Headache Unit, Neurology Department, Vall d’Hebron University Hospital, Headache and Neurological Pain Research Group, VHIR, Barcelona, Spain; ¹²Headache Center, “I. Amaducci” Neurological Clinic, Policlinico General Hospital, Bari, Italy; ¹³Center of Neurology, Vilnius University, Vilnius, Lithuania; ¹⁴Center of Neurology, Kardiolitos klinikos, Vilnius, Lithuania; ¹⁵Department of Neurology, Clínica Universidad de Navarra, Madrid, Spain; ¹⁶Unit of Headache and Neurosonology, Fondazione Policlinico Campus Bio-Medico and Neurology, Università Campus Bio-Medico di Roma, Roma, Italy; ¹⁷Department of Neurology, Wroclaw Medical University, Wrocław, Poland; ¹⁸Department of Neurology, Christian Hospital Unna and University of Duisburg-Essen, Ruhr Metropolitan, Germany

Background: Individuals with difficult-to-treat migraine, including resistant migraine (ResM) and refractory migraine (RefM), might experience treatment delays and undergo unnecessary diagnostic tests or misdiagnoses, which might influence treatment outcomes. We evaluated previous diagnostic tests and headache misdiagnoses in individuals with RefM and ResM in a multicenter study.

Methods: This analysis used baseline, cross-sectional data from the REFINE study, a multicenter, prospective observational study conducted in 15 European tertiary headache centers. Adults with episodic or chronic migraine were classified into RefM, ResM, or non-refractory/non-resistant migraine (NRNRM) groups. Baseline data were analyzed to assess the frequency of previous diagnostic tests and misdiagnoses.

Results: Overall, 689 participants were included with a median age of 46 years (interquartile range 36-53); 570 participants (82.7%) were female; 355 (51.5%) had NRNRM, 261 (37.9%) ResM, and 73 (10.9%) RefM. Diagnostic imaging was common; 335 participants (48.7%) had one and 237 (34.4%) multiple brain MRIs. Overall, 193 participants (28.0%) reported at least one prior headache misdiagnosis, most commonly cervical spine disorders and sinusitis. ResM and RefM participants underwent more diagnostic tests than NRNRM, though misdiagnoses were more frequent in NRNRM and ResM than in RefM (31.1%, 28.5%, and 15.1%, respectively; p=0.025). No significant association was found between misdiagnosis rates and age, sex, disease duration, or comorbidities.

Conclusion: Diagnostic tests and misdiagnoses are prevalent among individuals with migraine, regardless of treatment responsiveness. However, while diagnostic test frequency was associated with treatment resistance or refractoriness, this did not apply to misdiagnoses. These findings suggest the importance of timely and accurate diagnosis to prevent unnecessary testing and support early, appropriate treatment in all individuals with migraine.