Intractable Migraine (Status Migrainosus) 

Intractable migraine (or status migrainosus) is characterized by an episode similar to typical migraine but with even more severe symptoms, lasting over 72 hours. According to the International Classification of Headache Disorders (ICHD-3), it is considered a “complication of migraine.” 

What Causes It?

It is currently not well known why some people experience this extended form of migraine. Some research has shown that people who must manage depression, anxiety, or chronic pain conditions may be more likely to have extended periods of head pain as well.

What Are the Symptoms?

An intractable migraine episode is intense head pain that appears to be treatment-resistant, essentially a migraine gone out of control. Symptoms may include a throbbing headache (on one or both sides of the head), nausea, and hypersensitivity to light, sound, and sometimes smells. During this extended episode, pain may dissipate for a few hours, but then return.

How Is It Diagnosed?

Status migrainosus has the same severity of symptoms characteristic of a migraine episode, but with a longer duration than is typical with migraine. One study of people with status migrainosus found that the average duration of attacks was 4.8 weeks. 

For an individual experiencing this severe, prolonged head pain, the specialist will take a detailed medical history, conduct a thorough physical exam, and order tests such as neuroimaging to potentially rule out an underlying condition such as a cerebral tumor. 

How Is It Treated?

Taking medication early in an attack can be vital to stopping spreading sensitization in the brain that can make the migraine more and more severe. Many of the standard medications that treat migraine pain may not effectively help people with intractable migraine. Therapies that can potentially provide relief, as administered by a healthcare professional, include:

  • Dihydroergotamine (DHE-45, Migranal): Administered via injection, nasal spray, or intravenously, providing relief by narrowing dilated blood vessels. 
  • Sumatriptan: Administered via tablet, skin patch, injection, or nasal spray. 

These medications may also be combined with simple NSAIDs such as acetaminophen when the attack is particularly severe. 

Some people with status migrainosus seek treatment at a hospital Emergency Room, where medication(s) may be administered in combination (referred to as a migraine cocktail) in order to abort the severe headache, and might include ketorolac, dopamine receptor blockers such as metoclopramide, IV dihydroergotamine. and/or valproate.

Is It Preventable?

Preventive strategies and medications that reduce frequency and intensity of migraine days may help to avert episodes of status migrainosus. Medications may include several different classes such as beta blockers, anti-seizure drugs, and anti-CGRPs (calcitonin gene-related peptide). 

In addition, people with episodic or chronic migraine should maintain a journal tracking lifestyle and food triggers that can initiate or aggravate their migraine symptoms, and work with their healthcare team on a prevention and treatment plan individualized to their unique needs. 

What Causes It?

It is currently not well known why some people experience this extended form of migraine. Some research has shown that people who must manage depression, anxiety, or chronic pain conditions may be more likely to have extended periods of head pain as well.

What Are the Symptoms?

An intractable migraine episode is intense head pain that appears to be treatment-resistant, essentially a migraine gone out of control. Symptoms may include a throbbing headache (on one or both sides of the head), nausea, and hypersensitivity to light, sound, and sometimes smells. During this extended episode, pain may dissipate for a few hours, but then return.

How Is It Diagnosed?

Status migrainosus has the same severity of symptoms characteristic of a migraine episode, but with a longer duration than is typical with migraine. One study of people with status migrainosus found that the average duration of attacks was 4.8 weeks. 

For an individual experiencing this severe, prolonged head pain, the specialist will take a detailed medical history, conduct a thorough physical exam, and order tests such as neuroimaging to potentially rule out an underlying condition such as a cerebral tumor. 

How Is It Treated?

Taking medication early in an attack can be vital to stopping spreading sensitization in the brain that can make the migraine more and more severe. Many of the standard medications that treat migraine pain may not effectively help people with intractable migraine. Therapies that can potentially provide relief, as administered by a healthcare professional, include:

  • Dihydroergotamine (DHE-45, Migranal): Administered via injection, nasal spray, or intravenously, providing relief by narrowing dilated blood vessels. 
  • Sumatriptan: Administered via tablet, skin patch, injection, or nasal spray. 

These medications may also be combined with simple NSAIDs such as acetaminophen when the attack is particularly severe. 

Some people with status migrainosus seek treatment at a hospital Emergency Room, where medication(s) may be administered in combination (referred to as a migraine cocktail) in order to abort the severe headache, and might include ketorolac, dopamine receptor blockers such as metoclopramide, IV dihydroergotamine. and/or valproate.

Is It Preventable?

Preventive strategies and medications that reduce frequency and intensity of migraine days may help to avert episodes of status migrainosus. Medications may include several different classes such as beta blockers, anti-seizure drugs, and anti-CGRPs (calcitonin gene-related peptide). 

In addition, people with episodic or chronic migraine should maintain a journal tracking lifestyle and food triggers that can initiate or aggravate their migraine symptoms, and work with their healthcare team on a prevention and treatment plan individualized to their unique needs. 

Sources

  1. The Journal of Headache and Pain. Identifying and Managing Refractory Migraine: Barriers and Opportunities? D'Antona, Linda and Manjit Matharu. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6734232/#
  2. Mable. What is Status Migrainosus? https://www.trymable.com/blog/what-is-status-migrainosus?
  3. Migraine Australia. Intractable Migraine. https://www.migraine.org.au/intractable
  4. WebMD D.H.E.45 Injection: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. https://www.webmd.com/drugs/2/drug-57961/d-h-e-45-injection/details
  5. NHS. NHS Choices. https://www.nhs.uk/medicines/sumatriptan/
  6. Mable. What to Know ABout a Migraine Cocktail. https://www.trymable.com/blog/what-to-know-about-a-migraine-cocktail?

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