From the Guidelines
The best course of treatment for status migrainosus typically involves emergency department or inpatient management with aggressive parenteral therapy, including intravenous fluids, medications such as prochlorperazine, metoclopramide, or chlorpromazine, and NSAIDs like ketorolac, with consideration of DHE, magnesium sulfate, valproate, methylprednisolone, or lidocaine infusion for severe cases, as recommended by recent guidelines 1.
Key Considerations
- Status migrainosus is a severe and prolonged form of migraine that requires aggressive treatment to break the cycle of pain and nausea.
- Parenteral therapy is often necessary due to the severity of symptoms and the potential for medication overuse headache.
- A multimodal approach combining several medications and addressing contributing factors such as dehydration, stress, and sleep disruption is crucial for effective management.
Treatment Options
- Intravenous fluids for rehydration
- Intravenous medications such as prochlorperazine, metoclopramide, or chlorpromazine for pain and nausea
- NSAIDs like ketorolac for additional pain relief
- DHE, magnesium sulfate, valproate, methylprednisolone, or lidocaine infusion for severe, refractory cases
Preventive Therapy
- Should be initiated or adjusted to prevent recurrence after acute treatment
- May include medications such as propranolol, timolol, amitriptyline, divalproex sodium, or sodium valproate, as recommended by guidelines 1
Lifestyle Modifications
- Staying well hydrated
- Maintaining regular meals
- Securing sufficient and consistent sleep
- Engaging in regular physical activity
- Managing stress with relaxation techniques or mindfulness practices
- Pursuing weight loss for those who are overweight or obese, as highlighted in recent guidelines 1
From the FDA Drug Label
The safety of treating an average of more than 4 headaches in a 30-day period has not been established. The best course of treatment for a status migrainosus (migraine lasting more than 3 days) is not directly addressed in the provided drug labels.
- The labels discuss the treatment of migraine attacks, but do not provide guidance on the management of migraines that last more than 3 days.
- The dosing information provided is for the treatment of individual migraine attacks, with a maximum daily dose of 200 mg in a 24-hour period 2.
- There is no information on the best course of treatment for a migraine that lasts more than 3 days, and the safety of treating such a condition with sumatriptan has not been established.
From the Research
Status Migrainosus Treatment
- Status migrainosus is a severe and prolonged form of migraine that lasts more than 3 days 3
- The treatment for status migrainosus typically involves a combination of medications to alleviate symptoms and prevent further attacks
Medications for Status Migrainosus
- Corticosteroids, such as prednisone or dexamethasone, are commonly used to treat status migrainosus 3
- Triptans, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine may also be used to treat acute migraine attacks 4, 5
- Antiemetics may be used in combination with other medications to alleviate nausea and vomiting associated with migraine 6, 5
Treatment Approach
- The treatment approach for status migrainosus typically involves a stratified approach, with the goal of alleviating symptoms and preventing further attacks 5
- Patients with status migrainosus may require hospitalization or close monitoring to manage their symptoms and prevent complications 3
- Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, may be used to reduce the frequency and severity of migraine attacks 4, 7