What is the treatment for Status Migrainosus?

From the Guidelines

Status migrainosus treatment should involve aggressive management with intravenous medications, such as prochlorperazine, metoclopramide, or dihydroergotamine, in an emergency department or inpatient setting to break the cycle of this severe, prolonged migraine attack. The goal of treatment is to reduce morbidity, mortality, and improve quality of life by alleviating pain, nausea, and other associated symptoms. According to the provided evidence 1, steroid therapy, such as dexamethasone, may be considered for patients with status migrainosus, although the evidence is limited.

Key considerations in the treatment of status migrainosus include:

• Aggressive hydration with IV fluids to prevent dehydration
• Use of anti-emetic medications, such as prochlorperazine or metoclopramide, to control nausea and vomiting
• Administration of pain-relieving medications, such as dihydroergotamine or ketorolac, to reduce headache severity
• Adjunctive therapy with IV magnesium sulfate to enhance pain relief
• Initiation or adjustment of preventive therapy to prevent recurrence, including anticonvulsants, beta-blockers, or CGRP antagonists

It is essential to note that the treatment of status migrainosus requires a multidisciplinary approach, involving emergency department or inpatient care, to ensure timely and effective management of this neurological emergency. The provided evidence 1 highlights the importance of individualized treatment plans, taking into account the patient's medical history, comorbidities, and potential contraindications to certain medications.

In terms of specific medications, the evidence 1 suggests that:

• Prochlorperazine (Compazine) can effectively relieve headache pain, with a dosage of 25 mg orally or suppository, and a maximum of three doses per 24 hours
• Metoclopramide (Reglan) can be used to treat accompanying nausea and improve gastric motility, with a dosage of 10 mg IV or orally, 20 to 30 minutes before or with a simple analgesic, NSAID, or ergotamine derivative
• Dihydroergotamine (DHE) can be effective in treating status migrainosus, with a dosage of 1mg IV every 8 hours (up to 3mg/day), although it is contraindicated in pregnancy and cardiovascular disease.

From the Research

Status Migrainosus Treatment Options

• The treatment of status migrainosus typically involves a combination of medications, including intravenous fluids, corticosteroids, magnesium sulfate, anticonvulsive drugs, nonsteroidal anti-inflammatory drugs, antiemetics, and serotonergic agents 2.
• A staged approach to treatment may be used, initially combining subcutaneous sumatriptan with parenteral options including dopamine receptor antagonists, nonsteroidal anti-inflammatories, and acetaminophen 3.
• Combination treatment with parenteral magnesium sulfate, dihydroergotamine, antiepileptics, corticosteroids, and anesthetic agents may also be considered 3.
• The use of triptans, such as sumatriptan, and nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to be effective in the treatment of acute migraine attacks, including status migrainosus 4.
• Parenteral steroid and fluid supply are recommended as the first choice in treatment of status migrainosus 4.

Medication Considerations

• Dopamine receptor antagonists, such as prochlorperazine, have been shown to be effective in the treatment of status migrainosus 5.
• Opioids are not recommended for acute migraine treatment due to the risk of adverse CNS side effects, habituation, and addiction 5.
• Antiemetics may be used as a supplement to alleviate nausea and vomiting associated with status migrainosus 4.
• The use of acetaminophen is suitable for mild to moderate migraine attacks and remains the first choice for children and pregnant women 4.

Treatment Approach

• A stratified care approach may be used, where treatment is tailored to the severity of the migraine attack 4.
• For mild to moderate migraine attacks, oral NSAIDs are the first choice, with oral aspirin, combination analgesics, intravenous/intramuscular NSAIDs as alternatives 4.
• For moderate to severe attacks, oral or nasal spray triptans and ergotamine/caffeine compounds are recommended and should be administered in the early stage of migraine attacks 4.
• Treatment of status migrainosus and intractable migraine should focus on adequate fluid hydration and combination IV therapy with multiple nonopioid medications from multiple drug classes 5.