What is the treatment for status migrainous?

Treatment of Status Migrainosus

Systemic steroid therapy is the treatment of choice for patients with status migrainosus, which is defined as a severe, continuous migraine that may last up to one week. 1

First-Line Treatment Options

• Intravenous corticosteroids are the mainstay of treatment for status migrainosus, though there are limited high-quality studies documenting their efficacy 1, 2
• Parenteral fluids should be administered to address potential dehydration that often accompanies prolonged migraine attacks 3
• Antiemetics such as metoclopramide (10 mg IV) or prochlorperazine should be given to treat accompanying nausea and improve gastric motility, which is often impaired during prolonged migraine attacks 1

Second-Line Treatment Options

• Parenteral NSAIDs such as ketorolac (60 mg IM every 15-30 minutes, maximum 120 mg per day) can be effective due to their relatively rapid onset of action and six-hour duration 1
• Subcutaneous sumatriptan may be used, particularly when patients cannot take oral medications due to vomiting or when they rapidly reach peak headache intensity 1, 2
• Intravenous magnesium sulfate can be considered as part of combination therapy 3, 2

Third-Line Treatment Options

• Opioid analgesics such as meperidine (50-150 mg IM or IV) may be required for severe status migrainosus that doesn't respond to other treatments 1
• Butorphanol nasal spray (1 mg in one nostril, repeated in one hour if needed) can be considered when other treatments fail 1
• Dihydroergotamine (DHE) administered parenterally may be effective for refractory cases 3, 2

Important Considerations and Cautions

• Narcotic use should be limited and carefully monitored as it can lead to dependency, rebound headaches, and eventual loss of efficacy 1
• Non-oral routes of administration are preferred when significant nausea or vomiting is present 1
• Avoid oral ergot alkaloids, which are poorly effective and potentially toxic 1
• Monitor for medication overuse, which can worsen the condition and lead to chronic daily headaches 1

Treatment Algorithm

1. Initial Management:

   • IV fluids for hydration
   • IV corticosteroids (primary treatment)
   • Antiemetic therapy (metoclopramide or prochlorperazine)

2. If inadequate response within 1-2 hours:

   • Add parenteral NSAIDs (ketorolac)
   • Consider subcutaneous sumatriptan if not contraindicated

3. For refractory cases:

   • Consider IV magnesium sulfate
   • Consider parenteral DHE if not previously administered
   • Reserve opioids for cases not responding to above measures

4. Discharge Planning:

   • Evaluate need for preventive therapy to avoid recurrence
   • Consider prophylactic medications if patient experiences frequent attacks 1

Special Situations

• In patients with cardiovascular disease, avoid triptans and consider NSAIDs or antiemetics as primary therapy 1, 4
• For pregnant patients, acetaminophen and antiemetics are preferred; avoid NSAIDs and triptans 1
• In cases of medication overuse contributing to status migrainosus, discontinuation of the overused medication is essential, though this may temporarily worsen symptoms 1