Status Migraines

Another in the series of Migraine interviews.

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Have you ever had a migraine attack that continues for days or even weeks and just won’t respond to treatment? Status migraine can leave us debilitated and bedridden, not knowing what to do to end the pain. Christina Treppendahl is the founder and director of The Headache Center, Mississippi. She is also an award-winning family nurse practitioner who specializes in headache, and frequently helps patients develop effective strategies to treat such stubborn attacks.

What is a status migraine?

Ms. Treppendahl: If a disabling migraine goes on for longer than 72 hours, perhaps for days and sometimes even weeks, it’s called status migraine, also known as status migrainosus, refractory migraine, or intractable migraine. It can occur with or without aura and is a prolonged exacerbation of a migraine attack, rather than a rebound headache, as when abortive medicines wear off and a migraine goes but then returns. In status attacks, a peripheral sensitization occurs, whereby neurons in the meninges send signals to the deep brain, causing it to autoplay ever more pain that the brain does not know how to shut off. Along with the pain, other symptoms like nausea, sensitivity to light, noise, and smell, and a disability to function or eat are also triggered. Unfortunately, because there are no diagnostic tests or biomarkers for migraine and all test results are likely to be normal, doctors not specializing in headache often either suspect the patient of fraud or diagnose a psychiatric condition. And so there’s a problem of stigma attached to migraine generally and to status migraine in particular.

How common is status migraine?

Ms. Treppendahl: In the U.S. about 12% of the general population are subject to migraine but only about 2% have chronic migraine. Although most status migraine patients have had chronic migraine, those with only episodic migraine can also have status migraine. However, we’ve never had a report of an epidemiological study looking at which patients with episodic or chronic migraine have been in status, or how many of them there are.

What treatment options are there?

Ms. Treppendahl: Almost everybody who has chronic or status migraine should be offered a preventive. Abortive medicines include both NSAIDs, such as ibuprofen or Aleve, that can be bought over the counter; and diclofenac, a prescription medicine with level A evidence that it works in migraine. Migraine-specific abortives include triptans and ergotamines. Dihydroergotamine (DHE) typically has to be given either intramuscularly, intravenously, or intranasally, and because it tends to make people a little nauseated, it’s less in fashion than the triptans. Neuromodulation devices are another option, and we will soon have gepants and ditans to provide more categories of attack medications. If any one treatment fails, I offer a combination of a triptan, plus an NSAID, plus a dopamine receptor antagonist. For a status migraine, the most effective treatment is either a dopamine receptor antagonist, like metoclopramide (brand name Reglan), given intravenously, or prochlorperazine. Actually, prochlorperazine is the winner, hands down, against all other medications studied for status migraine.

Watch the full interview to find out:

  • What is status migraine?
  • How common is status migraine?
  • How can someone with chronic migraine know if they’re having individual daily attacks or one prolonged status migraine?
  • How do low- and high-pressure headaches compare to status migraine?
  • Is medication overuse headache, or rebound headache, sometimes confused with status migraine?
  • Are some people more at risk for status migraine than others? What are some of the risk factors?
  • What is the importance of prevention of migraine, particularly for those prone to status migraine?
  • What can patients do when acute treatment fails?
  • Do patients with status migraine always need to go to the emergency room or urgent care, or is there a backup plan they can follow to self-treat at home?
  • What type of medical professionals are best suited for treating status migraine?

Watch Christina Treppendahl’s interview preview, or order it as part of the Migraine World Summit package.