Defining response assessment criteria and inadequate response in acute migraine attack: A Delphi expert consensus from headache experts in India

Background Migraine is a prevalent neurological disorder affecting 14% to 29% of the Indian population, with significant regional variations. The selection of pharmacological agents for the acute management of migraine remains largely subjective, guided by individual patient preferences, economic considerations, and an empirical, trial-and-error approach. Although international guidelines are frequently referenced by neurologists in India, they provide limited direction on essential considerations such as medication tolerability, management of comorbid conditions, and patient-centered outcomes including satisfaction, restoration of functional ability, and individual preferences. Clinical approaches to acute migraine management differ widely, especially in the utilization of triptans and the criteria employed to determine insufficient therapeutic response. These consensus statements aim to establish a standardized framework for defining response assessment criteria and inadequate response to acute migraine therapy within the Indian clinical context. Methods A modified Delphi method was employed to develop consensus-based recommendations for defining response assessment criteria and inadequate response to acute migraine therapy in India. Statements were drafted following a literature review, and a steering committee of headache experts validated them using the Content Validity Index (CVI) for clinical relevance and clarity. Statements scoring >0.80 were deemed valid. The Delphi round involved a larger group of neurologists to achieve consensus, with statements achieving >75% consensus included in the final consensus. Results Fifteen statements were drafted under five themes: treatment response assessment criteria and timepoint, defining non-response to therapy, triptan usage, tolerability, and comorbidities. The steering committee validated these statements. A CVI score of 0.80 was achieved for 11 statements; four were modified, and one was added. A Delphi round with 19 headache experts helped achieve consensus (>75%) on 14/16 statements, with strong agreement on early treatment initiation, nasal triptan use in patients with nausea, and markers for inadequate response. The panel emphasized caution in prescribing NSAIDs and triptans to patients with comorbid conditions. Conclusion These consensus statements provide the first India-specific framework to standardize acute migraine care, reduce practice variability, and guide future research and health policy.