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Status migrainosus is a migraine that lasts more than 72 hours, and can be rather challenging to control. A few tips to tackle this are:
1. Adequately hydrate all patients (IV fluids are usually required, especially with severe nausea/vomiting)
2. Establish realistic expectations for the patient. A patient with chronic daily headaches will not be pain-free in the ED.
3. Use IV nonopioid medications for pain control
1st Line:
- Dopamine Antagonists: in increasing efficacy
- Metoclopramide
- Phenothiazines: prochlorperazine, promethazine and chlorpromazine
- Butyrophenones: droperidol and haloperidol
- NSAIDs: such as Ketorolac IV or IM
2nd Line:
- Corticosteroids: Do not treat the migraine in the ED, but prevent headache recurrence within 72 hours.
- Magnesium Sulfate: Has shown mixed efficacy. More likely to have a sustained benefit in patient with serum magnesium level of 1.3mg/dL or less.
- Valrpoic Acid: Be careful of combining it with Topiramate.
- Vasoconstrictors: Triptans, ergotamine, dihydroergotamine. Effective, but use is limited by contraindications.
- Opioids: Last resort