What is the best course of treatment for a 30-year-old female patient with a 5-day intractable migraine, worsened by bending or laying down, resistant to oral and intravenous (IV) medications, with normal magnetic resonance imaging (MRI) and computed tomography (CT) scans?

Suspect Spontaneous Intracranial Hypotension and Treat as Status Migrainosus

This clinical presentation—5-day intractable migraine worsening with bending/laying down despite normal imaging—strongly suggests spontaneous intracranial hypotension (SIH), which requires MRI with gadolinium and specific positioning protocols that standard MRI may miss. However, given failed oral/IV treatments and the duration qualifying as status migrainosus, immediate aggressive inpatient therapy is warranted while pursuing definitive diagnosis.

Immediate Inpatient Treatment Protocol

Gold Standard: IV Dihydroergotamine (DHE) Protocol

• Admit for repetitive IV DHE 0.5-1 mg every 8 hours for 2-3 days, which terminates intractable migraine cycles in 89% of patients (49/55) within 48 hours. 1, 2
• Pre-treat with metoclopramide 10 mg IV or prochlorperazine 10 mg IV given 30 minutes before each DHE dose to prevent nausea and provide synergistic analgesia. 1, 3
• This protocol has sustained benefit in 71% of patients (39/55) at mean 16-month follow-up, making it superior to all alternatives for breaking prolonged migraine cycles. 2

Add Corticosteroids for Status Migrainosus

• Administer IV methylprednisolone 80-125 mg daily OR dexamethasone 10-20 mg IV for 2-3 days specifically to break the status migrainosus cycle and prevent recurrence. 1
• Corticosteroids are indicated for status migrainosus (not routine migraine) to reduce inflammation. 1

Critical Diagnostic Consideration: Rule Out Spontaneous Intracranial Hypotension

Why This Presentation Suggests SIH

• Positional worsening (worse bending/laying down) is pathognomonic for low CSF pressure headaches, NOT typical migraine which usually improves when supine. [General Medicine Knowledge]
• Standard CT/MRI miss 20-30% of SIH cases; you need MRI brain/spine WITH gadolinium looking specifically for pachymeningeal enhancement, venous sinus engorgement, and CSF leak. [General Medicine Knowledge]
• If SIH confirmed, treatment shifts to epidural blood patch (70-90% success rate), NOT migraine protocols. [General Medicine Knowledge]

Immediate Next Steps While Treating

• Order MRI brain AND spine with gadolinium with radiologist aware of SIH suspicion. [General Medicine Knowledge]
• Consider upright vs supine MRI if available to demonstrate positional changes. [General Medicine Knowledge]
• If DHE protocol fails within 48 hours, strongly pursue SIH workup including possible CT myelography or digital subtraction myelography. [General Medicine Knowledge]

Assess and Address Medication-Overuse Headache (MOH)

Critical Question to Answer

• Determine if patient has been using ANY acute medications >2 days/week (>10 days/month for triptans, >15 days/month for NSAIDs), as this creates MOH which paradoxically worsens headaches and prevents treatment response. 1, 3
• The 5-day duration with treatment resistance is classic for MOH superimposed on migraine. 1

If MOH Present

• The DHE protocol simultaneously treats the acute attack AND breaks the MOH cycle by providing effective relief without perpetuating medication overuse. 2, 4
• Do NOT discharge with opioids or butalbital compounds, which have questionable efficacy and worsen the MOH cycle. 3, 1

Initiate Preventive Therapy Immediately

First-Line Preventive Options

• Start propranolol 80-240 mg/day (titrate from 40 mg BID) OR topiramate 50-200 mg/day (titrate from 25 mg daily) during admission, as preventive therapy requires 2-3 months to assess efficacy and must begin now. 1, 5
• Alternative first-line: amitriptyline 30-150 mg/day at bedtime, particularly if comorbid insomnia or tension-type headache. 1, 5

Rationale for Immediate Prevention

• Any patient requiring >2 days/week of acute treatment OR experiencing attacks lasting >3 days meets absolute criteria for preventive therapy. 1, 5
• Preventive therapy reduces attack frequency by ≥50% and restores responsiveness to acute treatments. 1

Discharge Planning and Rescue Medication

Appropriate Rescue Options

• Prescribe subcutaneous sumatriptan 6 mg auto-injector for breakthrough attacks (most effective route, 59% pain-free at 2 hours, 15-minute onset). 3, 1
• Alternative: intranasal DHE as home rescue if subcutaneous sumatriptan contraindicated. 1, 6

Strict Frequency Limits

• Educate that ALL acute medications must be limited to maximum 2 days per week (8-10 days per month) to prevent MOH recurrence. 3, 1
• If needing rescue >2 days/week despite preventive therapy, escalate preventive treatment or consider CGRP monoclonal antibodies. 1

Alternative if DHE Contraindicated or Unavailable

Second-Line Inpatient Protocol

• IV valproate sodium 250 mg over 60 minutes every 8 hours for 4 days showed 69% improvement in chronic migraine refractory to multiple preventives in pilot study. 7
• However, this has far less evidence than DHE protocol and should only be used if DHE contraindicated (cardiovascular disease, uncontrolled hypertension, pregnancy). 7, 1

Common Pitfalls to Avoid

• Do NOT discharge with opioids (hydromorphone, oxycodone) as they have no proven efficacy for migraine, cause dependency, and perpetuate MOH. 3, 1
• Do NOT assume normal CT/MRI excludes all secondary causes—specifically SIH requires dedicated imaging protocols. 1
• Do NOT allow patient to continue frequent acute medication use while waiting for preventive therapy to work—this guarantees treatment failure. 3, 1
• Do NOT use IV valproate as first-line when DHE is available—DHE has 35+ years of evidence vs. one small pilot study for valproate. 2, 4, 7