It was only 3 days ago when you started developing that familiar pain above your right eyebrow, but it seems more like a month. Telling yourself that maybe this time the pain spontaneously would fade away, for the first few hours you tried to ignore it…but from years of bitter experience you knew better than that. Once this particular ball gets rolling, it’s all downhill.

Blend together, say, the onset of your period, a stressful day at work and an annoying dust-up with your partner, and…voila! There you have the perfect recipe for an episode of migraine. That faint piercing discomfort is going to settle itself down behind your eye in its favorite location, put up its feet and then merrily turn up the volume. In parallel with the increasing and inescapable pain, a retreat to total darkness will escalate from luxury to necessity. There must be absolute silence. And just the thought of food will bring on the dry heaves.

Meet friends for a drink after work? Hah! Prepare dinner? Forget it! A romantic make-up with that partner? There…is…NO…way.

Sound familiar? Most migraineurs have experienced precisely this or something similar, and for many it becomes an all too frequent intrusion that drains away quality of life. Thankfully, in most cases the individual migraine episode is self-limited and, as if grown exhausted by the effort of imposing such dreadful symptoms, ceases spontaneously. Or with sleep. Or, oddly enough, with vomiting.  Or with administration of an effective medication.

Not uncommonly, however, a migraine episode will just keep on rolling, and no amount of bedrest, cold compresses, relaxation techniques or medication administered seems to make any real difference. When the individual migraine episode extends to exceed 72 hours in duration, it is referred to as status migrainosus.

Aside from the misery you experience from the prolonged headache and associated symptoms, what is the downside of status migrainosus? We know that a major risk factor for the “transformation” of episodic migraine into chronic migraine is increasing frequency of migraine episodes. Put simply, if what we term “migraine” represents a genetically hypersensitized biologic circuit within the nervous system that clinically expresses that hypersensitivity by generating migraine symptoms, then the more migraine episodes one experiences, the more active that circuit becomes. If the migraine circuit becomes sufficiently sensitized, the afflicted individual is always on the brink of having a migraine or is acutely symptomatic. That person now has “chronic migraine”.

It logically follows that experiencing prolonged episodes of migraine – ie, status migrainosus – accelerates the development of chronic migraine or reinforces chronic migraine once it has developed. Even worse, status migrainosus may directly cause chronic migraine. How long can status migrainosus last? By definition, at least 3 days, but in some unfortunate cases it may never stop. What begins as a simple migraine episode persists indefinitely, and the result is constant headache that may fluctuate in intensity but never entirely remit. For years.

While this is a relatively rare occurrence, the risk of status migrainosus directly evolving into chronic migraine underscores the importance of intervening early to terminate the acute migraine episode. “Treat early/treat hard” is the mainstay of all acute migraine treatment. If an attack of acute migraine reflects acute sensitization of an inherently sensitive biologic circuit, then the longer the attack persists (and the more acutely sensitized the circuit becomes), then the more difficult it will be to stop the momentum of that biologic boulder that has picked up speed as it rolls down the hill. Three aspirin and a caffeinated soda taken early for migraine headache can be more effective than intravenous narcotics administered in the emergency room 24 hours later, after the headache has become severe. There is evidence that the most potent self-administered medication for rescue from severe migraine headache, injectable sumatriptan, may lose its effectiveness if treatment is delayed until after the migraine circuit has reached a certain level of acute sensitization. 

But what if you do everything right – treat early with an adequate dose of an appropriate medication; use a more potent therapy when the headache persists and increases despite early treatment – and the migraine attack stubbornly refuses to back off? What can you do then? The unvarnished truth is: not a whole lot. If you have developed status migrainousus, if your headache is persistent and severe despite optimal self-administered therapy, you well may require provider-administered therapy to end the attack successfully. Occasionally status migrainosus will respond to a short course of high-dose oral steroid (eg, prednisone 60 mg daily for several days), but often treatment with intravenous medications and hydration will be required. And intravenous therapy typically means an emergency room, an urgent care center or, if you are lucky enough to have one available to you, a “headache rescue room” (more on this later).

The ER is not a great option for obtaining treatment of acute migraine headache. Waits can be long, lights bright and the environment noisily chaotic. The providers are unlikely to know you personally, and they may have developed a certain cynicism in regards to patients seeking medication for pain. Even if they are sympathetic to your situation they may be distracted by the critically ill patients in the adjacent exam rooms. Urgent care centers generally are less busy and more convenient than ERs, but they also tend to lack much in the way of therapeutic options. 

Whether it’s an ER or an urgent care center, you are more likely to experience a positive outcome if you come bearing a treatment plan recommended by your usual headache provider. A note from that provider serves as evidence that someone has made the effort to establish that you have migraine, and the treatment plan the provider recommends will help guide management, avoid delays and maximize the likelihood of a good treatment outcome. One of my patients knows from experience that for her most severe migraine episodes a combination of intravenous hydration, magnesium and a steroid invariably relieves her pain and prevents early headache recurrence. With my note in hand testifying to this, she is received much more positively by a busy ER staff than a similar patient who is unknown and lacking any formal medical records from the treating physician. 

Now, what was that about a “headache rescue room”?  Some physician offices and clinics that sub-specialize in headache medicine provide their patients with the option of coming in on an urgent/as needed basis for intravenous infusion therapy when they call to report they are experiencing a severe migraine headache that has resisted self-administered therapy.  The “rescue room” may vary from something as simple as a regular exam or procedure room temporarily used to treat the patient with acute migraine to a more elaborate facility involving physically separate space intended exclusively for that purpose.  More important than the physical details of the facility utilized is the availability to patients of an attractive alternative to seeking care at an ER or simply suffering in silence at home.  In our own “headache rescue room” located within the George Washington University headache clinic patients can be evaluated rapidly by providers who know them and treated with evidence-based intravenous protocols customized to their particular needs and previous experience.  The cost involved is a fraction of that associated with an ER visit, and in prospective studies we have found high rates of favorable clinical outcome and patient satisfaction. For more on this topic, see the “Rescue Room” article that follows. 

The best treatment for status migrainosus, “the migraine attack that refuses to stop”, is to prevent it from developing in the first place by treating the attack early.  If the headache persists and worsens despite early treatment, use a self-administered “rescue” medication.  If all else fails, seek care at an ER or urgent care center, but do so armed with information provided by your usual headache provider.  If you are lucky enough to have access to a “headache rescue room”, use it.  

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