Status Migrainosus
By: Brooklyn A. Bradley, BS; Medically edited by Dr. Deena Kurvilla, MD
Photo by Alex Green [Pexels]
Migraine is a debilitating condition, affecting millions worldwide. While most migraine attacks resolve within a few hours or a day, there is a more severe form known as status migrainosus. In today’s blog post, we will be diving deeper into status migrainosus, and discussing its symptoms, causes, and treatment options.
Status migrainosus is defined as a debilitating migraine attack that lasts more than 72 hours [1]. This complication of migraine can occur in a patient with migraine without aura and/or migraine with aura, and must be typical of prior attacks except for severity and duration [2]. Thus, a typical migraine usually resolves within hours or a day with treatment. However, status migrainosus can go on for days and is resistant to typical treatments. The symptoms of status migrainosus can vary from patient to patient, but they usually follow the pattern of a person’s typical migraine symptoms; however, they are much more intense and persistent. For example, if a patient experiences photophobia during their typical migraine attack and they now have progressed to status migrainosus, their sensitivity to light may be exaggerated and intensified.
Some studies have reported that primary central nervous system dysfunction, trigeminovascular activation, and central/trigeminal sensory sensitization form the foundation of the attack in status migrainosus, and influence its overall severity and duration [3]. Activation of the trigeminovascular system leads to the release of neurotransmitters which trigger inflammation. In the case of central and/or trigeminal sensory sensitization, pain pathways respond to stimuli that would normally be non-painful. Researchers have found that certain genes may be involved in making people more likely to have long-lasting migraine attacks like status migrainosus [3, 4]. In addition, scientists have identified specific genetic markers (changes in DNA) that seem to be linked to more intense migraine attacks. Some of these genetic markers may explain why some people with status migrainosus have a harder time finding relief from standard treatments like triptans [4]. There are also reports of structural changes in the brain during a status migrainosus episode. For example, in one case, brain scans (i.e., MRI or PET scan) illustrated swelling in certain areas of the brain during a migraine attack [5]. Once the migraine episode ended, the swelling decreased. This suggests that brain changes like swelling, reduced blood flow, or reduced brain activity could occur during a status migrainosus episode; however, these changes seem to subside once the attack ends [5].
Possible triggers of status migrainosus include overuse of acute migraine medications (medication overuse headache), dehydration, poor sleep habits, stress or changes in routine, certain foods, environmental factors, and underlying conditions. In women, hormonal fluctuations can also trigger status migrainosus in certain cases. Patients at risk may include those with chronic migraine or a history of frequent headache, patients who may have a history of medication overuse headache, and those who have a genetic predisposition to migraine.
For diagnosis of status migrainosus, providers will rely on a thorough history and physical exam. Imaging may be ordered to rule out other serious conditions. Regarding treatment options for status migrainosus, they can vary depending on the patient and whether or not the treatment is being administered in the hospital, on an outpatient basis, and/or is a long-term management strategy. On an outpatient basis, prescription medications might include triptans, anti-inflammatories, or anti-nausea medications depending on the patient’s symptoms or even anesthetic injections such as nerve block and trigger point injection [2]. If status migrainosus is a chronic issue, preventive measures like Botox or CGRP inhibitors can be used. If treatment is being received in the hospital, intravenous fluids may be provided for dehydration and IV medications may be provided depending on the patient’s symptoms [2]. Overall, it is important that patients with status migrainosus discuss prevention of future episodes with their provider, whether that is through lifestyle modifications, keeping a migraine diary, or by talking about the role of preventive treatments.
In conclusion, status migrainosus is a severe prolonged migraine attack that lasts longer than 72 hours and does not respond to typical treatments. It can significantly impact a person’s daily life. It is vital to understand the causes and symptoms of status migrainosus in order to manage it effectively.
References:
- Pescador Ruschel MA, De Jesus O (2024) Migraine Headache. In: StatPearls. StatPearls Publishing, Treasure Island (FL)
- Kamourieh S, Rozen T, Anderson JM (2024) Chapter 25 – Status migrainosus. In: Swanson JW, Matharu M (eds) Handbook of Clinical Neurology. Elsevier, pp 413–439
- Goadsby PJ, Hargreaves R (2008) Refractory migraine and chronic migraine: pathophysiological mechanisms. Headache 48:799–804. https://doi.org/10.1111/j.1526-4610.2008.01157.x
- Esserlind A-L, Christensen AF, Steinberg S, et al (2016) The association between candidate migraine susceptibility loci and severe migraine phenotype in a clinical sample. Cephalalgia 36:615–623. https://doi.org/10.1177/0333102415570492
- Kim Y-J, Kwon SU (2015) Recurrent steroid-responsive cerebral vasogenic edema in status migrainosus and persistent aura. Cephalalgia 35:728–734. https://doi.org/10.1177/0333102414553820