Status Migrainosus - The Basics Updated

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One of the most difficult situations that those of us with migraines can face is a migraine attack that doesn't go away in a day and is still there the next day. This type of migraine is called status migrainousus. If the migraine attack has breaks of up to 12 hours due to medications or sleep, it can still be status migrainosus.

This can be confusing for those of us with chronic migraine who have a migraine pretty much every day. In such circumstances, asking our doctors to help us distinguish between the two is the way to go.

To help standardize diagnosing so that we're all on the same page, the International Headache Society's International Classification of Headache Disorders, 3rd Edition (ICHD-3) is the standard for descriptions and diagnostic criteria for migraine and other headache disorders.

The ICHD-3 on Status Migrainosus:

_1.4.1 Status migrainosus _

Description:

A debilitating migraine attack lasting for more than 72 hours.

Diagnostic criteria:

  1. A headache attack fulfilling criteria B and C

  2. Occurring in a patient with 1.1 Migraine without aura and/or 1.2 Migraine with aura, and typical of previous attacks except for its duration and severity

  3. Both of the following characteristics:

    1. unremitting for >72 hours1
    2. pain and/or associated symptoms are debilitating2
  4. Not better accounted for by another ICHD-3 diagnosis.

Notes:

1 Remissions of up to 12 hours because of medication or sleep are accepted.
2 Milder cases, not meeting criterion C2, are coded 1.5.1 Probable migraine without aura.

Comments:

Headache with the features of 1.4.1 Status migrainosus may often be caused by medication overuse. When headache in these circumstances meets the criteria for 8.2 Medication-overuse headache, code for 1.3 Chronic migraine and 8.2 Medication-overuse headache but not for 1.4.1 Status migrainosus. When overuse of medication is of shorter duration than 3 months, code for the appropriate migraine subtype(s) only.

Summary and Comments:

Status migrainosus is a debilitating migraine attack that lasts more than 72 hours, but may have a break of up to 12 hours due to medication or sleep. There doesn't seem to be a strong consensus among doctors regarding whether status migrainosus is an emergency situation or not.

Here are some significant considerations:

  • If our migraine abortives (triptans, ergotamines, or Midrin equivalents) fail to work on a migraine attack, we should have rescue medications to be used at that time. Rescue medications can't abort the migraine, but they can often offer symptomatic relief that allows us to rest or sleep, giving the migraine more time to stop. Deep, restful sleep is an excellent migraine abortive, but without symptomatic relief, many migraineurs cannot reach that stage of sleep. Having rescue medications available is not an unreasonable request. If you and your doctor haven't discussed rescue treatment, please make a note to bring it up at your next appointment.
  • Timing is vital. If we have a migraine that seems to be status migrainosus, and a weekend or holiday is approaching, we need to call our doctors for advice. Emergency rooms and urgent care facilities are not the best places for migraine treatment. It's far better to call our own doctors than to wait until the ER or urgent care are our only options.
  • Recent research concluded that, "Ineffective acute migraine treatment is associated with a 2.5- to 3.5-fold increased risk of transformation to chronic migraine."2 Status migrainosus could be an indication that the treatment being used to treat a migraine attack when it occurs is not working well for us. Especially given this recent research, it benefits to work with our doctors to find the most effective acute treatments possible.

More Helpful Articles - Our Basics Series:


Resources:

1 Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808  10.1177/0333102413485658.

2 Bravo, Thomas P., MD; Schwedt, Todd J., MD. "Poor Acute Treatment May Lead to Chronic Migraine." Neurology Times. March 4, 2015.

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PurpleRibbonTiny Teri1

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