An Overview of Status Migrainosus

A.K.A. Intractable Migraines

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Status migrainosus (sometimes called intractable migraines) affect less than 1 percent of people with migraines. What differentiates them from other migraines is that they last for 72 hours or longer, are often resistant to typical migraine medications, and have symptoms that are especially debilitating.

Symptoms

The symptoms of status migrainosus are similar to those of some other types of migraines and include:

  • A throbbing headache on one side of the head of moderate to severe intensity
  • Worsening pain with normal physical activity like walking
  • Dizziness
  • Nausea and/or vomiting
  • Photophobia (sensitivity to light) and phonophobia (sensitivity to sound)
  • Aura

In a regular migraine with aura or without aura, symptoms last between four and 72 hours. With status migrainosus, they last 72 hours or longer.

Causes

Causes of status migrainosus can include:

  • Overuse of medicines used to treat acute headaches and migraines: Headaches in this category are known as medication overuse or rebound headaches.
  • Changes to medicines you take, especially hormone treatments like birth control pills, hormone therapy for menopause, or antidepressants
  • Changes in weather
  • Lack of sleep
  • Skipping meals
  • Stress
  • Dehydration

Diagnosis

There is no single test that can diagnose any form of migraine. Instead, certain criteria must be met and other potential causes ruled out.

According to the International Classification of Headache Disorders (ICHD-3), status migrainosus only occurs in people with another form of migraine, hence, a doctor may diagnose status migrainosus based on symptoms alone if a person has had migraines before. Overall criteria include:

  • Symptoms that occur in a patient with migraine with and/or without aura and that are typical of previous attacks except for duration and severity
  • Symptoms, particularly a headache, that last for over 72 hours
  • Symptoms that are debilitating
  • Symptoms are not better accounted for by another ICHD-3 diagnosis

Sometimes, neurological performance tests or magnetic resonance imaging (MRI) scans may be performed to rule out other rare causes, such as a brain injury or brain tumor.

Treatment

People with status migrainosus typically do not find relief with their usual migraine medications. For this reason, these migraines are often treated in​ the emergency room. Treatments may include:

  • Intravenous (IV) fluids
  • Medications to control nausea and vomiting, like Compazine (prochlorperazine)
  • Triptans, especially subcutaneous sumatriptan or DHE (dihydroergotamine), followed by an intravenous NSAID, like Toradol (ketorolac)
  • A class of medications called dopamine receptor antagonists (dopamine blockers): This class includes drugs like Reglan (metoclopramide), Prolixin (fluphenazine), and Thorazine (chlorpromazine hydrochloride), which have been shown to be especially effective in treating status migrainosus.
  • Steroids like dexamethasone: One study of a small sample of people showed that 80 percent of patients with status ​migrainosus had significant pain relief when they took dexamethasone twice a day for four days.
  • Intravenous sodium valproate, an anti-seizure medication

Prevention

Strategies to prevent status migrainosus are generally the same as those used to prevent migraine with or without aura. Keeping a journal to record triggers of each migraine you experience can help you avoid them in the future.

Other strategies include alternative treatments—including acupuncture, massage, and certain herbs and supplements—and lifestyle measures, such as reducing stress, exercising, avoiding certain foods, staying hydrated, and getting enough sleep.

You may also want to talk to your doctor about taking medications that are used to prevent migraines. These include:

  • Antihypertensives (blood pressure lowering agents), such as metoprolol, propranolol, and timolol
  • Antidepressants, such as Elavil (amitriptyline) and Effexor (venlafaxine)
  • Anticonvulsants: These include valproate products, divalproex sodium, sodium valproate, and Topamax (topiramate).

Since medications used to treat acute migraines such as triptans, ergotamines, opioids and butalbital compounds can result in overuse headaches (which are associated with status migrainosus), try to limit your use of these drugs if possible

A Word From Verywell

If you're experiencing a migraine that is more severe than usual and does not go away within three days, notify your healthcare provider, who will advise you on how to proceed.

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