A Cross-Sectional Survey of Prevailing Opinions from Headache Specialists Regarding Status Migrainosus Management

Presented at the AAN Annual Meeting, April 22-27, 2023 

Authors: Jennifer Robblee, Robert Vann, Christopher Fitzpatrick, Michelle Murphy, Sutapa Ray, Stephen Shrewsbury, Sheena Aurora

Objective: To gather the prevailing opinions of headache specialists regarding status migrainosus (SM) management based on clinical experience and exposure to scientific data.

Background: SM is a debilitating migraine complication with intense symptoms lasting >72 hours. Although SM epidemiologic data are unclear, a recent population-based study in Minnesota reported that 15% of individuals experienced a recurrent SM attack during the following year. Although no evidence-based treatment guidelines for SM exist, treatment can include steroids, nerve blocks, nonsteroidal anti-inflammatory drugs, triptans, ergotamine, neuroleptics, and dihydroergotamine mesylate (DHE). Consensus on defining clinical trial endpoints for SM to improve future research and outcomes is an unmet need. 

Design/Methods: A cross-sectional phone survey was conducted with 33 headache specialists from tertiary headache centers across the United States. Verbal responses to 8 questions asked at random about SM patterns observed and treatment protocols used for SM management were given.

Results: Most headache specialists reported treating SM patients every week, sometimes several patients per day. Cases were frequently observed at the clinic, but some required hospital admission when clinics were considered inadequate for SM treatment. Most headache specialists used drug infusions, the Raskin or modified DHE protocol, or steroids to treat SM. While DHE is considered the gold standard to completely break recurrence, drug inaccessibility and hesitation to send patients to hospitals limit its use. Most headache specialists reported refractory patients being more prone to recurrent SM attacks. Treatment goals included avoiding emergency room (ER) visits and providing patients with autonomy and at-home treatments (eg, self-injections, oral steroids).

Conclusions: Headache specialists treat multiple SM patients per week and value treatments that break the headache and offer sustained pain relief while avoiding ER visits. Although DHE was viewed favorably for SM, it was underutilized and often only as a last resort due to accessibility issues.