By Robert Kaniecki, M.D.
Director of the Headache Center at the University of Pittsburgh
THE CASE
Joan experiences three to four migraines per month, usually lasting two hours with treatment or 24 hours without treatment. On this occasion, she contacted the office with a migraine that just won’t break. She described a typical attack that failed to respond either to her triptan tablets or her over-the-counter remedies. She had severe pain and nausea.
DISCUSSION
One of the most frequent problems fielded by healthcare providers is that a headache will not break. The term status migrainosus (or status migraine) is applied to those migraine attacks that extend beyond a period of 72 hours, regardless of treatment. In such situations, acute headache therapies are either completely ineffective or only temporarily effective, with patients complaining that the headache goes away, but continues to come back. In either case, migraine treatment apparently fails to completely interrupt the physiologic chain of events responsible for migraine headache and its associated features of nausea, vomiting and sensitivities to light, noise and smell. Like a trick candle on a birthday cake, the migraine flame refuses to be extinguished despite a patient’s best attempts.
In response to comments from patients that their medication isn’t working, patients are often switched from one triptan or pain reliever to another, or they may be given narcotics to treat the ongoing pain. In our experience at the Headache Center at the University of Pittsburgh, these steps are generally unproductive, since the regular treatment is usually effective and only occasionally fails to halt a migraine attack. Neither clinicians nor patients should expect acute migraine therapies to be effective for each and every attack. At best, one should expect them to work 70% of the time if headaches are frequent (more than 10 days per month) or 90% of the time if treatment is infrequent. Occasional failures of acute medication generally do not necessitate throwing the baby out with the bath water.
Cases of status migrainosus should be assessed for any underlying triggers or perpetuating factors. The most common precipitating factors for status migrainosus include stressors, hormonal imbalances, medication alterations (most commonly hormonal or antidepressant therapies), weather pattern shifts, trauma to the head or neck, or significant disruptions in sleep or meal patterns. Surgical procedures involving the sinuses, teeth or jaw may result in an extended flair in migraines. Occasionally, an underlying illness, such as a sinus infection or the flu, is involved. One must also be vigilant for the development of an underlying neurologic condition such as meningitis or a brain tumor, but it is extraordinarily rare for these conditions to present as status migrainosus. Should illness or a neurologic condition be suspected as provoking status migrainosus, evaluation by a healthcare provider is mandatory.
Generally, status migrainosus can be managed on an outpatient basis. Since dehydration and sleep disruption frequently perpetuate the headache, we recommend adequate hydration (60-80 ounces of water per day) and simple sleep aids. Medications to help control pain and nausea may be necessary, while suppository formulations of anti-nausea medications may be required for vomiting. Injectable anti-migraine therapies such as sumatriptan or dihydroergotamine, and analgesics such as ketorolac can be quite useful. These prescriptions may be provided by phone and administered in the home setting.
Should pain or vomiting remain intractable, intravenous hydration and medications may be delivered at an outpatient infusion center, urgent care facility, emergency room or hospital inpatient unit. Intravenous versions of anti-nausea medications, dihydroergotamine and ketorolac may also be administered.
For some time, headache clinicians have used brief courses (3-7 days) of steroids, such as prednisone, dexamethasone, or a medrol dose pack, to treat refractory migraine headaches. We recently completed a study on the effectiveness of corticosteroids in the management of status migrainosus. Patients given the steroid dexamethasone were much more likely to see their headaches improve within a 72-hour treatment course than those given an ergotamine medication or managed chiefly with anti-inflammatory and anti-nausea medications. Although corticosteroids carry some risk, and although some patients may be unable to take them due to certain underlying conditions such as diabetes, we find the use of steroids in status migrainosus helpful for some patients.
In summary, clarifying potential triggers for a stretch of headache days is often helpful, but status migrainosus can occur randomly and without noticeable provocation. Management with hydration, control of pain and nausea, and occasionally with corticosteroids usually proves quite beneficial. Although changes to underlying medications are generally unnecessary, frequent occurrences of status migrainosus might require an adjustment of medication.
