A frustrated, worried reader asked us: “I’ve had this same migraine for two weeks. This has never happened to me before. How do I break this?”
This problem can happen to anyone with migraine. When our typical medicines stop working and migraine keeps going beyond the usual 4-72 hours, we may be experiencing a complication of migraine called Status Migrainosus. In A Neurologist’s Guide to Status Migrainosus Therapy in the Emergency Room, Drs. Gelfand and Goadsby state, “It must be stated at the outset that an ED visit for migraine represents a failure of appropriate outpatient management, and modifications in the patient’s rescue plan need to be made to avoid such visits in the future.”
The missing link
One of the common failures in acute treatment of migraine is the lack of rescue treatments. A rescue treatment is different than the typical medicine you use to abort a migraine. Most often, patients are prescribed a triptan, NSAID, or ergot-derivative to abort a migraine attack. These are acute medications that can be used at the first sign of symptoms. When these treatments fail, it is appropriate to use a rescue treatment. Most commonly, rescue treatments are strong NSAIDS like toradol or difenolac, but can also be diphenhydramine, anti-emetics (like Zofran, Compazine, or Phenergan), or even opioids. A rescue treatment should be a medicine that you can administer at home when your abortives fail. The goal of a rescue treatment is to prevent you from having to seek treatment at the ER.
If you do not have a rescue treatment available for home use when abortives fail, then please talk to your doctor. This is an essential part of migraine management that is often overlooked. For decades, I would ask my doctor what to do if my triptan failed. His only response was to visit the ER. It wasn’t until I pushed back, insisting that a visit to the ER for a cocktail shot of Toradol, Benadryl, and Phenergan was unnecessarily expensive and wasteful did he agree to prescribe these medicines to me for home use. Starting in 2013, I began using IM injections of Toradol with a Phenergan suppository as my rescue treatment. Thanks to this, I have been able to avoid the ER ever since. Instead, a few times each year, I am able to treat unresponsive attacks at home, saving me thousands of dollars and avoiding the unnecessary use of the ER.
Getting Immediate Help
Unfortunately, all of this good advice doesn’t help you stop a prolonged attack in progress. If you’ve already exhausted all of your home treatments, and the attack is still going strong after 72 hours, you do need to call your doctor. In most cases he or she will recommend you go to the emergency room for evaluation and treatment. Most likely, the problem is Status Migrainosus which can be stopped in the ER or with a brief inpatient stay.
Common medicines used to treat Status Migrainosus
When migraine is prolonged, there is an increased risk of dehydration which can make treating Status Migrainosus more difficult. In most ERs, the first step in treating Status Migrainosus is IV fluids to correct any dehydration that may be present, especially if the patient has been vomiting.
If someone presents at the ER with migraine and has not been prescribed a triptan, the first option is usually to administer a subcutaneous injection of sumatriptan.
Toradol (ketorolac) is most often used in the ER to treat Status Migrainosus. There are numerous studies to support its effectiveness, which can be as high as 80%. The typical dose is 60 mg via IV. When toradol fails or is not available, 75 mg of diclofenac is another option.
Chlorpromazine (Thorazine), Procholorperazine (Compazine), and Promethazine (Phenergan) are commonly used to treat Status Migrainosus when first-line NSAIDs fail. They all have the risk of causing temporary dystonia or akathisia. Diphenhydramine is often used as a pretreatment to prevent these side effects. Chlorpromazine (Thorazine) is an older medicine with a long history of effectively breaking status migrainosus. Prochloroperazine (Compazine) is more commonly used in children. The typical dose is 10 mg IV or IM or 25 mg suppository. Promethazine has fallen out of common use due to the risk of soft tissue injury. All phenothiazines have the secondary benefit of antiemetic properties and may also be used as rescue treatments at home.
Both droperidol (Inapsine) and haloperidol (Haldol) have been used when other measures have failed. They are not typically first-line options because both can cause uncontrollable limb movements, restlessness, and agitation (akathisia).
A typical dose of DHE is 0.5 to 1 mg IV, repeated up to a total of 3 mg over 24 hours. Nausea is a common side effect, so patients are often pretreated with an antiemetic such as Zofran, Phenergan, or Compazine. It has a proven efficacy rate of 60% within 1 hour of administration. Unfortunately, there has been a shortage of DHE in many locations, which is also contributing to rising costs. Outside of major headache centers, many doctors are reluctant to use it.
Although commonly used, there is little evidence that corticosteroids are effective at treating Status Migrainosus. In fact, a meta-analysis of existing studies showed that migraine often recurred 24-72 hours after discharge when corticosteroids were used.
Also known as Depakote, a typical dose ranges from 300 to 1200 mg IV. It is contraindicated during pregnancy, liver disease, and kidney disease.
While generally avoided when treating migraine, opioids are occasionally used to break intractable pain. They are not as effective as other treatments. When used long term, they can contribute to the development of chronic migraine and medication overuse headache. They may be considered for short-term use during pregnancy when many migraine-specific treatments are contraindicated.