What is the best course of treatment for a 30-year-old female with a 7-month history of progressively worsening migraines, currently experiencing her worst migraine lasting 48 hours with minimal improvement on oral and intravenous (IV) medications, normal head computed tomography (CT) scan, and normal laboratory results?

Status Migrainosus Requiring Hospital Admission

This patient meets criteria for status migrainosus (migraine lasting >72 hours with minimal response to treatment) and requires hospital admission for intravenous therapy with dihydroergotamine (DHE) or a combination of IV metoclopramide plus ketorolac, along with corticosteroids to break the cycle. 1, 2, 3

Immediate Diagnostic Considerations

Before initiating aggressive treatment, recognize this clinical scenario has critical red flags that warrant careful evaluation:

• The 7-month progressive worsening pattern is atypical for primary migraine, which typically has a more stable course over time 4
• While the head CT is normal, this does not exclude all secondary causes - venous sinus thrombosis, intracranial hypotension, or early mass lesions may not appear on non-contrast CT 4
• However, given the normal CT and labs, and assuming no other red flags (thunderclap onset, fever, focal neurologic deficits, papilledema), proceeding with status migrainosus treatment is appropriate 5, 4

Definition and Admission Criteria

Status migrainosus is defined as a migraine attack lasting more than 72 hours (this patient is at 48 hours but trending toward this threshold) with debilitating symptoms despite treatment 2, 3. This patient clearly meets admission criteria based on:

• Intractable migraine unresponsive to oral and IV medications 3
• Severe disability preventing normal function 3
• Need for parenteral therapy and close monitoring 2, 3

First-Line Inpatient Treatment Protocol

Primary Option: IV Dihydroergotamine (DHE) Protocol

DHE is the gold standard for status migrainosus in the inpatient setting, with well-established efficacy for breaking prolonged migraine cycles 1, 6, 3, 7:

• Administer DHE 0.5-1 mg IV every 8 hours for 2-3 days (typical inpatient protocol) 3, 7
• Pre-treat with metoclopramide 10 mg IV or prochlorperazine 10 mg IV 30 minutes before each DHE dose to prevent nausea and provide synergistic analgesia 1, 3
• DHE has 47-70% efficacy for acute migraine relief within 4 hours, with sustained benefit over 24 hours 6

Critical contraindications to DHE that must be excluded:

• Ischemic heart disease, previous MI, or significant cardiovascular disease 1, 6
• Uncontrolled hypertension 1, 6
• Pregnancy or breastfeeding 6
• Concurrent use of triptans within 24 hours 6
• Basilar or hemiplegic migraine 5

Alternative Option: IV Metoclopramide + Ketorolac Combination

If DHE is contraindicated or unavailable, use IV metoclopramide 10 mg plus IV ketorolac 30 mg every 6-8 hours 1:

• This combination provides both direct analgesic effects and addresses nausea 1
• Ketorolac has rapid onset (within 30 minutes) and 6-hour duration with minimal rebound headache risk 1
• Metoclopramide provides independent analgesic benefit beyond antiemetic effects through central dopamine receptor antagonism 1

Essential Adjunctive Therapy: Corticosteroids

Add IV methylprednisolone 80-125 mg daily or dexamethasone 10-20 mg IV for 2-3 days to break the status migrainosus cycle 2, 3:

• Corticosteroids are specifically indicated for status migrainosus (not routine acute migraine) to reduce inflammation and prevent recurrence 2
• This is distinct from routine acute migraine treatment where corticosteroids have limited evidence 1

Additional Supportive Measures

• IV hydration with normal saline - many patients with prolonged migraine are dehydrated from poor oral intake and vomiting 2, 3
• IV magnesium sulfate 1-2 grams over 15-30 minutes can be added for additional benefit 2
• Continue antiemetics as needed (metoclopramide 10 mg IV or prochlorperazine 10 mg IV every 6-8 hours) 1, 2

Critical Medications to AVOID

Do NOT use opioids or butalbital-containing compounds for this patient:

• These medications lead to dependency, rebound headaches, and medication-overuse headache 5, 1, 3
• The patient has already failed oral and IV medications, suggesting possible medication overuse 5
• Opioids should only be considered as absolute last resort when all other options are contraindicated 5, 1

Do NOT continue triptans during inpatient treatment:

• Triptans are contraindicated within 24 hours of DHE due to risk of prolonged vasospasm 6
• Frequent triptan use (>10 days/month) contributes to medication-overuse headache 1

Medication-Overuse Headache Assessment

This patient's 7-month progressive worsening raises concern for medication-overuse headache (MOH):

• MOH occurs when acute medications are used >2 days per week (>10 days/month for triptans, >15 days/month for NSAIDs) 1
• The progressive worsening pattern and minimal response to treatment are classic for MOH 5, 1
• Breaking the MOH cycle requires stopping overused medications and using different therapeutic approaches (hence DHE or the metoclopramide/ketorolac combination) 5, 3

Transition to Preventive Therapy

While treating the acute status migrainosus, initiate or optimize preventive therapy:

• This patient clearly meets criteria for preventive therapy: >2 attacks per month producing disability for >3 days 5, 8
• First-line preventive options include propranolol 80-240 mg/day, topiramate 50-200 mg/day, or amitriptyline 30-150 mg/day 1, 8
• CGRP monoclonal antibodies should be considered if oral preventives fail, with efficacy assessed after 3-6 months 1
• Preventive therapy requires 2-3 months for oral agents to show full benefit 1, 8

Expected Length of Stay and Discharge Planning

Plan for 3-5 day admission for status migrainosus treatment 3:

• Most patients require 2-3 days of IV DHE or combination therapy to break the cycle 3
• Longer stays may be needed for patients with severe intractable migraine or significant medication overuse 3

At discharge:

• Provide rescue medication (subcutaneous sumatriptan 6 mg or nasal DHE) for breakthrough attacks 5, 1
• Strict education on medication frequency limits: no more than 2 days per week for any acute medication 5, 1
• Ensure preventive therapy is started and follow-up arranged within 1-2 weeks 8

Common Pitfall to Avoid

The biggest mistake is discharging this patient with more of the same oral or IV medications that have already failed 3. Status migrainosus requires a different therapeutic approach (DHE or prolonged IV combination therapy with corticosteroids) to break the cycle, not simply repeating failed treatments 2, 3.