Treating status migrainosus in the emergency setting: what is the best strategy?

ABSTRACT

Introduction: Migraine is a disabling primary headache disorder with unknown exact pathomechanism. Status migrainosus (SM) is a complication of migraine (with or without aura), representing an attack that lasts for more than 72 h. There is a paucity of data published with regard to its pathomechanism and therapeutic options.

Areas covered: The authors review the literature on SM from PubMed published between 1999 and January 2018. The authors specifically look at the therapeutic possibilities of SM in the emergency department in patients that have or have not already been treated with serotonergic agents. Additional discussion is given to the rare complications of migraine.

Expert opinion: SM is a devastating condition; therefore, the primary goal is to prevent its development with proper acute and prophylactic migraine medication. If this treatment fails, the patient should be treated in the emergency setting. Due to the severity of the condition, parenteral pharmacotherapy is recommended. However, high-quality randomized trials are lacking. The currently available data suggest the use of intravenous fluids, corticosteroids, magnesium sulfate, anticonvulsive drugs, nonsteroidal anti-inflammatory drugs, antiemetics, and serotonergic agents for the treatment of SM. Still, there is a need for personalized and causal therapy for migraine sufferers.

KEYWORDS:

• Anticonvulsive drugs
• antiemetics
• corticosteroids
• emergency
• intravenous hydration
• magnesium sulfate
• migraine
• nonsteroidal anti-inflammatory drugs
• serotonergic agents
• status migrainosus
• treatment

Article highlights

• Status migrainosus, as a migraine complication, is a debilitating migraine attack lasting for more than 72 h and its pharmacological management is challenging in the emergency setting.

• Therapeutic options of status migrainosus depend on whether the patient has already received serotonergic agents (dihydroergotamine or triptans) or not for the present attack.

• Drugs currently used parenterally for the treatment of status migrainosus in the emergency department include intravenous fluids, corticosteroids, magnesium sulfate, anticonvulsive drugs, nonsteroidal anti-inflammatory drugs, antiemetics, and serotonergic agents.

• Major adverse events (chest tightness for sumatriptan, drowsiness and nausea for dexamethasone, liver toxicity for acetaminophen and akathisia, and tardive dyskinesia for antiemetics/antidopaminergic drugs) should be kept in mind.

• In the case of rare manifestations of migraine, i.e. migraine with prolonged aura, persistent aura without infarction, migraine aura status and ictal epileptic headache ketamine, anticonvulsants, antidepressants, calcium ion channel antagonists, and diuretics should be considered.

This box summarizes the key points contained in the article.

Acknowledgments

We are grateful to Levente Szalárdy MD PhD for his valuable contribution in proofreading the manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was supported by Economic Development and Innovation Operational Program (Gazdaságfejlesztési és Innovációs Operatív Program, GINOP-2.3.2-15-2016-00034) financed by the European Union and by the MTA-SZTE Neuroscience Research Group of the Hungarian Academy of Sciences as well as by the University of Szeged.