Introduction Migraine affects over 200 million people in China, with females 3× more affected, and imposes severe disability. Conventional pharmacological therapies often fail to achieve adequate control, as supported by evidence-based guidelines1, and 40% of refractory patients develop Medication-Overuse Headache (MOH), defined by excessive analgesic use leading to hyperalgesia and dependency2. MMAE, initially explored for endovascular management of chronic subdural hematomas3, relieves migraine by blocking abnormal neurovascular signals – its mechanism is closely linked to the clinical significance of the middle meningeal artery, which plays a key role in migraine pathophysiology4. The Chongqing case (2025) demonstrated its efficacy: the patient, unresponsive to analgesics, recovered rapidly post-MMAE. Notably, MMAE is not first-line; it is reserved for patients failing standard management steps5. Core unresolved challenges MOH Differentiation: MOH and pure migraine have distinct pathophysiologies (MOH involves trigeminal sensitization), as elaborated in studies on refractory migraine management2, but Xu et al’s trial did not stratify patients by MOH status. MOH patients require analgesic withdrawal before MMAE, a key step in refractory migraine management5. Bilateral Embolization Safety: Most patients in trials have bilateral headaches but undergo unilateral MMAE. Long-term risks of bilateral occlusion (e.g., chronic subdural hematoma, cranial nerve dysfunction) remain unevaluated, even though MMAE’s safety for subdural hematomas has been reviewed in recent literature3. Efficacy Interpretation: Xu et al reported reduced headache frequency but no significant pain severity improvement – a “frequency-severity dissociation” suggesting MMAE targets initiation, not amplification pathways, consistent with evidence-based pharmacological treatment principles for migraine1. Precision medicine roadmap A three-phase framework (see Figure 1) addresses these gaps: Figure 1.: A three-phase roadmap centered on personalization, reversibility, and combination therapy – core principles of precision medicine. Predictive Patient Selection: Use superselective MMA lidocaine tests to identify responders (temporary pain relief), avoiding unnecessary interventions – an approach aligned with personalized management strategies for refractory migraine4,5. Reversible Interventions: Adopt biodegradable embolic agents with a 3–6 month trial window – convert to permanent embolization only if efficacy is sustained; otherwise, restore vascular patency. Combination Therapy: Pair MMAE with CGRP-targeted agents (e.g., erenumab, a monthly self-injectable approved in China) to address both initiation (MMAE) and amplification (CGRP inhibition). Neuromodulation (e.g., vagus nerve stimulation) aids patients with comorbid anxiety/sleep disorders. Conclusion MMAE shows great potential for refractory migraine, validated by early clinical cases and trials. To advance its use, future studies must: (1) stratify outcomes by MOH/aura status; (2) test bilateral embolization’s long-term safety; (3) validate the precision roadmap. Integrating MMAE with CGRP inhibitors and MOH management will ultimately deliver personalized, low-risk care for millions of patients. Ethical approval Not applicable. This study did not involve human participants, human tissue samples, or animal experiments, so ethical approval was not required. Consent Not applicable. No human subjects were enrolled in this study, therefore written or verbal informed consent was not applicable.
Li et al. (Wed,) studied this question.