What is the treatment for status migranosus?

Treatment of Status Migrainosus

The first-line treatment for status migrainosus (migraine lasting >72 hours) should be intravenous dihydroergotamine (DHE) administered at 1 mg every 8 hours for 3-5 days, combined with antiemetics such as metoclopramide. 1

First-Line Parenteral Therapy

• IV dihydroergotamine (DHE) is the cornerstone of status migrainosus treatment, administered at 1 mg every 8 hours for 3-5 days in an inpatient or outpatient infusion setting 1, 2
• Antiemetics (particularly metoclopramide) should be administered before DHE to prevent nausea and improve gastric motility 1, 3
• Parenteral steroids (such as dexamethasone 4 mg orally twice daily for 3 days) and IV fluid rehydration are important adjunctive therapies 4, 5
• Subcutaneous sumatriptan may be used in combination with parenteral options including dopamine receptor antagonists and NSAIDs 2

Second-Line Options

• Nerve blocks using local anesthetics (1-2% lidocaine) targeting the supraorbital, supratrochlear, auriculotemporal, and greater occipital nerves have shown a 24% success rate in rendering patients pain-free within 24 hours 5
• Ketorolac (60 mg intramuscularly) has demonstrated an 11% success rate in achieving pain-free status within 24 hours 5
• Naratriptan (2.5 mg twice daily for 5 days) has shown similar efficacy to ketorolac with an 11% success rate 5

Post-Treatment Prevention of Relapse

• Following IV DHE treatment, short-term prophylaxis with oral methylergonovine maleate (0.4 mg three times daily for 7 days) may prevent relapse into status migrainosus 1
• This approach has shown promise in extending the therapeutic benefit of IV DHE, with 2 out of 3 patients maintaining improvement at 7 weeks post-discharge 1

Refractory Cases

• For cases that do not respond to standard treatments, general anesthesia using agents that stimulate GABA receptors (propofol and isoflurane) in combination with fentanyl has been reported as effective in breaking the pain cycle 6
• This approach should be considered only in severe cases that have failed all other treatment options 6

Treatment Success Evaluation

• Treatment success rates depend on the time allowed for the intervention to work - the longer the timeframe (24-96 hours), the more likely patients are to achieve and maintain a pain-free status 5
• Current treatment approaches have limited success rates: dexamethasone (31%), nerve blocks (24%), ketorolac (11%), and naratriptan (11%) for achieving pain-free status within 24 hours 5

Important Considerations and Precautions

• DHE is contraindicated in patients with cardiovascular disease, uncontrolled hypertension, and during pregnancy 7
• Triptans should be limited to ≤10 days/month to avoid medication overuse headache 3
• Opioids should be avoided due to the risk of dependency, rebound headaches, and eventual loss of efficacy 3, 4
• Careful monitoring for adverse effects is essential, particularly with ergot derivatives which may cause nausea, diarrhea, and vasoconstriction 1

Follow-up Care

• Active follow-up is essential to determine treatment outcomes and provide the opportunity to review both diagnosis and treatment strategies 8
• Evaluation should include attack frequency, attack severity, and migraine-related disability 8
• Headache calendars are extremely useful for capturing these measures and require little time commitment if completed only on symptomatic days 8