What is the treatment for status migraines?

Treatment for Status Migraines

For status migraines, first-line treatment should be NSAIDs such as ibuprofen (400-800mg), naproxen sodium (275-550mg), or aspirin (650-1000mg), followed by triptans as second-line therapy if NSAIDs are ineffective. 1, 2

First-Line Treatment Options

NSAIDs

• Ibuprofen: 400-800mg every 6 hours (maximum 2.4g daily)
• Naproxen sodium: 275-550mg every 2-6 hours (maximum 1.5g daily)
• Aspirin: 650-1000mg every 4-6 hours (maximum 4g daily)
• Combination therapy: Aspirin-acetaminophen-caffeine (e.g., Excedrin Migraine) has shown significant effectiveness with NNT of 9 for pain freedom at 2 hours 2

Administration Considerations

• Early treatment during an attack is crucial for optimal outcomes 2
• For patients with significant nausea/vomiting, consider:
  • Non-oral routes of administration
  • Adding antiemetics such as metoclopramide or prochlorperazine to improve gastric motility and treat nausea 2

Second-Line Treatment: Triptans

If NSAIDs are ineffective, triptans should be used as second-line therapy 1, 2:

• Sumatriptan:
  • Oral: 50-100mg (maximum 200mg in 24 hours)
  • Subcutaneous: 6mg for severe attacks or significant nausea/vomiting (most effective route with NNT of 2.3 for pain-free at 2 hours) 3
  • Intranasal: 20mg (effective when oral route is compromised)
• Rizatriptan: 10mg orally for patients weighing ≥40kg 2

Sumatriptan works by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibiting pro-inflammatory neuropeptide release 4. The 100mg oral dose has been shown to be more effective than 50mg for pain-free and headache relief at 2 hours 5.

Combination Approaches

Consider combining triptans with fast-acting NSAIDs to prevent recurrence 1. This approach has shown better efficacy than either medication class alone for moderate to severe migraine attacks 2.

Medications to Avoid

• Oral ergot alkaloids: Poorly effective and potentially toxic 1
• Opioids and barbiturates: Questionable efficacy and risk of dependency 1, 2

Important Cautions and Contraindications

• Triptan contraindications: Cardiovascular conditions, Wolff-Parkinson-White syndrome, history of stroke/TIA, peripheral vascular disease, uncontrolled hypertension 2
• Medication overuse risk: Limit sumatriptan to no more than 9 days per month, NSAIDs to no more than 15 days per month, and OTC medications to no more than 14 days per month to prevent medication overuse headache 2

Preventive Treatment Considerations

For patients with frequent status migraines (≥2 attacks per month with disability lasting ≥3 days), consider preventive therapy 1, 2:

• Beta-blockers: Propranolol (80-240mg/day), timolol (20-30mg/day)
• Antidepressants: Amitriptyline (30-150mg/day)
• Anticonvulsants: Topiramate (25-100mg/day), divalproex sodium (500-1000mg/day)

Preventive therapy should be continued for 2-3 months to adequately assess efficacy 1.

Treatment Algorithm for Status Migraines

1. Start with NSAIDs (ibuprofen, naproxen, or aspirin)
2. Add antiemetic if significant nausea/vomiting
3. Switch to triptans if no response to NSAIDs within 2 hours
4. Consider combination therapy (triptan + NSAID) for severe or recurrent attacks
5. Evaluate for preventive therapy if attacks occur ≥2 times per month with significant disability

Early intervention is key to successful treatment of status migraines, with treatment during the mild pain phase showing significantly better outcomes than treating established attacks with moderate or severe pain 5.