II. Indications

  1. Migraine Headache refractory to home care (6-72 hours)
  2. Headache Red Flag (e.g. Thunderclap Headache)

III. Causes

IV. History

V. Examination

VI. Diagnostics

VII. Precautions

  1. See Headache Red Flags
  2. Do not miss serious Headache Causes

VIII. Preparations: Antiemetics

  1. Dopamine-antagonists are preferred
    1. Prochlorperazine (Compazine) with IV hydration
      1. Often effective for aborting intractable Headache
      2. Consider with Diphenhydramine 12.5 to 50 mg IV to reduce risk of Akathisia, Dystonia
      3. Adults: 10 mg IV
      4. Child: 0.15 mg/kg IV
    2. Metoclopramide (Reglan) 10 mg IV
      1. Excellent first-line agent for Migraine with Nausea
      2. Colman (2004) BMJ 329(7479): 1369-73 [PubMed]
    3. Droperidol (Inapsine) 0.625 mg IV or IM
      1. FDA black box warning due to QT Prolongation risk
      2. EKG monitoring for single or cummulative doses above 1.25 mg
    4. Diphenhydramine (Benadryl)
      1. Consider prophylactically or as needed for Anti-emetic associated Dyskinesia
  2. Avoid agents less effective in treating Headache
    1. Promethazine (Phenergan) 12.5 mg IV
    2. Hydroxyzine

IX. Preparations: Serotonin Agonist

  1. Precautions
    1. Do not use if CAD, CVA, Uncontrolled Hypertension
    2. Do not use with MAO inhibitors, and Exercise caution with other serotonergic agents (e.g. SSRI)
  2. Dihydroergotamine mesylate (DHE)
    1. DHE 0.5 to 1 mg IV every 8 hours up to cummulative maximum of 3 mg
    2. Migranal 1 spray in each nostril and may repeat once after 15 minutes
  3. Triptans
    1. Sumatriptan (Imitrex) intranasl, oral or subcutaneous
    2. Zolmitriptan (Zomig) intranasal or oral

X. Preparations: Analgesic or Anti-inflammatory

  1. Ketorolac (Toradol)
    1. Dose: 30 mg IV (60 mg IM)
  2. Dexamethasone
    1. Dose: 4-10 mg IV (or 8-24 mg PO)
    2. Hydrocortisone or Methylprednisolone IV could be used as alternative (however Dexamethasone is preferred)
    3. May prevent Headache recurrence in following 48-72 hours
    4. Singh (2008) Acad Emerg Med 15(12): 1223-33 [PubMed]
  3. Intranasal Lidocaine
    1. Position patient supine with head hyperextended with tilt to 30 degrees
    2. Lidocaine 4%, 0.5 ml of solution dripped into nostril on affected side over 30 seconds
  4. Magnesium
    1. Variable efficacy, but at least one study demonstrates efficacy (compared with Decadron and Reglan)
      1. Shahrami (2015) J Emerg Med 48(1):69-76 +PMID:25278139 [PubMed]
  5. Opioids (avoid if possible)
    1. Still used in 47% of emergency visits

XI. Preparations: Other agents that have been used historically

  1. Antipsychotics with Analgesic and Antiemetic properties
    1. Chlorpromazine (Thorazine) 12.5 mg IV q20 min prn x3
    2. Haloperidol (Haldol) 5 mg IV (pre-bolus 500 to 1000 cc of IV fluids)
  2. Anticonvulsant - Valproic Acid (Depacon)
    1. Depacon 300-1000 mg in 100 cc NS IV over 30 minutes

XII. Preparations: Status Migrainosus (severe refractory Migraine)

  1. Reconsider Headache differential diagnosis
    1. See Organic Headache
    2. See Headache Red Flag
  2. Experimental (preliminary data only)
    1. Lidocaine
    2. Propofol (sub-anesthetic dosing)
      1. Follow same protocols as for Conscious Sedation (but dose is ~25% of those doses)
        1. Obtain Informed Consent
        2. Monitoring as with Conscious Sedation
        3. Observe for 2 hours following administration
      2. Dosing (listed for completeness, experimental only)
        1. Adults: 20-30 mg every 5 minutes to effect (average total dose 100 mg)
        2. Child: 0.5 mg/kg every 5 minutes to effect
      3. Efficacy
        1. Highly effective, resolving Headache in most patients within 30 minutes (and remained awake)
        2. Krusz (2000) Headache 40(3): 224-30 [PubMed]
        3. Soleimanpour (2012) BMC Neurol 12:114 [PubMed]
        4. Sheridan (2012) Pediatr Emerg Care 28(12): 1293-6 [PubMed]
  3. References
    1. Claudius and Mecklar in Majoewsky (2012) EM:RAP 12(10): 11-12

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Ontology: Status Migrainosus (C0338489)

Concepts Disease or Syndrome (T047)
MSH D008881
ICD10 G43.2 , G43.901
SnomedCT 193038003, 230467008
Japanese 片頭痛発作重積, ヘンズツウホッサジュウセキ
Czech status migraenosus, Status migrenosus, migrenózní status
French État migraineux, Etat de mal migraineux
German Status migraenosus
English status migrainosus (diagnosis), status migrainosus, Status migrainosus NOS, status migrainus, Status migrainosus, Status migrainus, Status migrainosus (disorder), migraine; status, migrainosus; status, status; migraine, status; migrainosus, Status Migrainosus
Spanish Estado Migrañoso, estado migrañoso (trastorno), estado migrañoso, Status migrañoso
Korean 편두통 지속상태
Portuguese Estado de Mal Enxaquecoso, Estados de enxaqueca
Hungarian Status migrainosus
Italian Stato emicranico
Dutch migraine; status, migrainosus; status, status; migraine, status; migrainosus, status migrainosus, Status migrainosus