Status migrainosus


Status migrainosus

Description, Causes and Risk Factors:

The term "status migrainosus" was coined by Taverner in 1978, at which time he described patients with prolonged, resistant migraine attacks that resulted in incapacitation. These patients could have severe dehydration and electrolyte depletion secondary to nausea and vomiting.

In 1983, status migrainosus was further defined as a "disabling headache of the migraine type which has lasted for at least 72 hours."

Status migrainosus is an attack of severe migraine without aura that lasts more than 72 hours and is not attributable to another disorder. Care must be taken as apparent status migrainosus may be secondary to an acute neurologic or medical disorder.

From 126 questionnaire responses, factors thought to be responsible for triggering status migrainosus included emotional stress, depression, abuse of medications, anxiety, diet, hormonal factors, and multiple nonspecific factors.

Patients with frequent or severe headache are prone to overuse analgesics, opioids, ergotamine, or a combination thereof. Overuse consists of regular daily use of simple or combination analgesics containing barbiturates or sedatives more than 3 times a week, ergotamine tartrate more than twice a week, or triptans more than 3 times a week. Overuse can result in a number of serious consequences that include headache refractoriness, tolerance to and dependence on symptomatic medications, and refractoriness to preventive medication, which may lead to status migrainosus and chronic daily headache. Stopping the symptomatic medication usually causes withdrawal symptoms, a period of increased headache, and eventually headache improvement in many, but not all, patients.

Most patients with chronic daily headache overuse symptomatic medication. Medication overuse may play a part in both the transformation of episodic migraine or tension-type headache into status migrainosus and chronic daily headache and the maintenance of the chronic daily headache syndrome. Status migrainosus does not necessarily indicate medication overuse, especially early in the course of the disorder.

Symptoms:

The symptoms of status migrainosus are similar to symptoms of a typical migraine. Along with pain in the head, common symptoms may include:

    Sensation of sparkling lights and loss of vision (aura).

  • Vomiting.

  • Difficulty thinking properly.

Because status migrainosus lasts for at least three days, prolonged vomiting and pain can lead to dehydration and fatigue due to sleep loss.

Diagnosis:

Status migrainosusis a clinical diagnosis. Diagnostic investigations are performed for the following reasons:

    Exclude structural, metabolic, and other causes of headache that can mimic or coexist with migraine.

  • Rule out comorbid diseases that could complicate headache and its treatment.

  • Establish a baseline for treatment and exclude contraindications to drug administration.

  • Measure drug levels to determine compliance, absorption, or medication overdose.

The choice of laboratory and/or imaging studies is determined by the individual presentation. For example, in an older person with compatible findings (eg, scalp tenderness), measurement of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may be appropriate to rule out temporal/giant cell arteritis.

Visual field testing should be performed in patients with persistent visual phenomena.

Neuroimaging (CT scan or MRI) should precede LP to rule out a mass lesion and/or increased intracranial pressure.

Treatment:

Treating status migrainosus can be complicated. The longer the condition has been present, the less it tends to respond to normal abortives and the greater the chance central sensitization and allodynia will become a problem. Additionally, because the Migraine attack is so prolonged, there are often other symptoms that require diligent management as well.

Suppository, IV and injection therapies tend to be more effective at this point than oral Migraine treatments due to prolonged gastric stasis (stomach doesn't empty properly), nausea, vomiting and malabsorption. Your doctor's choice may include drugs such as magnesium sulfate, DHE, Benadryl, valproic acid, lidocaine, steroids or a combination of these and other drugs.

When steroids are used for status migrainosus, it is often more effective to give Depo-Medrol and saline IV in a large bolus over 30 minutes or more, followed by up to a month or more of prednisone step down therapy.

Nausea and vomiting may result in dehydration and electrolyte imbalance and should be treated normally with IV solution, electrolytes and anti-nausea medication. Anti-nausea medication used in concert with some types of rescue/pain medications result in a synergistic effect in which the two drugs together are more effective than if they were used separately.

Some physicians feel that a trial of non-oral indomethacin is prudent in these patients to be sure they are not suffering hemicrania continua.

NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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