What is status migraineosis?

Status Migrainosus: Definition and Management

Status migrainosus is defined as a persistent debilitating migraine attack lasting for more than 72 hours with little reprieve, leading to functional disability. 1 It is recognized as a complication of migraine with or without aura in the International Classification of Headache Disorders.

Diagnostic Criteria

• Status migrainosus represents a migraine attack that continues beyond the typical 4-72 hour duration specified in standard migraine diagnostic criteria 2
• The headache must meet the criteria for migraine (with or without aura) but persists despite treatment attempts 1
• The prolonged attack causes significant functional disability and often requires emergency or specialized care 1, 3

Clinical Presentation

• Persistent headache with typical migraine characteristics:
  • Unilateral location (though can be bilateral)
  • Pulsating quality
  • Moderate to severe intensity
  • Aggravation by physical activity 2
• Associated symptoms that may persist throughout the attack:
  • Nausea and/or vomiting
  • Photophobia (sensitivity to light)
  • Phonophobia (sensitivity to sound) 2
• In cases with aura, the aura symptoms typically resolve within the expected timeframe (5-60 minutes), but the headache phase continues 2

Treatment Approaches

First-Line Management

• Most headache specialists (76%) prefer to initially treat status migrainosus with outpatient medications at home rather than immediate hospitalization 4
• The top five medications used by headache specialists for status migrainosus are:
  • Corticosteroids (71.4%)
  • NSAIDs (50.1%)
  • Neuroleptics/dopamine antagonists (46.9%)
  • Triptans (30.6%)
  • Dihydroergotamine (DHE) (21.4%) 4

Emergency/Inpatient Management

• When outpatient management fails, parenteral therapy is recommended due to the severity of the condition 3
• Treatment options include:
  • Intravenous fluids for hydration
  • Parenteral corticosteroids (such as dexamethasone)
  • Magnesium sulfate
  • Anticonvulsants
  • Parenteral NSAIDs (such as ketorolac)
  • Antiemetics/neuroleptics
  • Serotonergic agents 3, 2
• Steroid therapy is considered the treatment of choice for status migrainosus, though high-quality studies documenting efficacy are limited 2

Clinical Considerations and Challenges

• Current treatment approaches for terminating status migrainosus show limited success rates:
  • Dexamethasone: 31% success rate
  • Nerve blocks: 24% success rate
  • Ketorolac: 11% success rate
  • Naratriptan: 11% success rate 5
• Many headache specialists (69.4%) do not wait for the full 72-hour duration before treating a severe refractory migraine attack as status migrainosus 4
• The condition represents a substantial healthcare burden and can lead to emergency department visits and hospitalizations 1

Prevention

• The primary goal should be preventing the development of status migrainosus through proper acute and prophylactic migraine medication 3
• Patients with frequent or severe migraine attacks should be considered for preventive therapy to reduce the risk of status migrainosus 2
• Early intervention during a migraine attack may help prevent progression to status migrainosus 4, 6

Research Gaps

• There is limited epidemiological knowledge about status migrainosus 5
• No evidence-based treatment guidelines or rational-driven assessment of successful treatment outcomes exist 5
• The underlying pathophysiology is not fully understood, and it remains unclear whether status migrainosus represents a distinct biological state beyond established migraine pathophysiology 1
• High-quality randomized trials for treatment are lacking 3

Status migrainosus represents a severe complication of migraine that requires prompt recognition and aggressive treatment to reduce suffering and disability. The development of specific antimigraine medications has reduced the number of headaches that persist after initial treatment, but more research is needed to establish optimal management strategies.