One of the peculiarities of migraine attacks from the perspective of those affected is that they always occur when you have absolutely no use for them. As unpredictable as the individual course of a migraine is, it also follows the rules: the migraine is over after 72 hours at the latest. This biological constant is also reflected in the diagnostic criteria for migraine (headache classification of the International Headache Society IHS): A main criterion for migraine is an untreated duration of the headache attacks of 4 to 72 hours.
But unfortunately there is an exception to this rule: status migraenosus. This term is used to describe migraine attacks that, for whatever reason, last longer than 72 hours. Status migraenosus is listed by the IHS among migraine complications.
If you ask patients whether they have ever suffered from such long migraine attacks, the majority will confirm this. For most of those affected, this will have been an exception. For some, however, long, grueling and debilitating migraine attacks are the norm. Three constellations in particular are typical:
- Menstruation-associated status migraenosus
A common trigger for long migraine attacks are the hormonal changes at the time of menstruation. After two to three days of migraines, which can be treated more or less well, the headaches subside. The woman seems to have overcome the attack, only to have to experience, after a short break of a few hours, that the migraine returns on the other side of her head, where it rages for just as long. - Treatment-resistant migraine attacks
Many patients actually have effective attack medication available, which they can usually rely on even during severe attacks. But again and again there are attacks in which the otherwise effective concept fails. The first dose of triptan does not bring any relief, and a second dose of triptan, taken against better judgment, fizzles out without any effect. You take painkillers that have never really helped anyway and right, they aren't helping now either. All that remains is the bed and the hope that the migraine will go away on its own at some point. But this attack in particular does not go away after three days. - Status migraenosus due to medication overuse
Here the situation is initially completely opposite. The migraine can be easily stopped with medication, usually a triptan, but only apparently. As triptan levels fall, migraines return after 12 to 24 hours, a phenomenon known as recurrent headache. Of necessity, you repeat the triptan intake (which is possible once within 24 hours within the scope of the application rules) and it works again: the migraine pain subsides. But this time the effect doesn't last long. The next few hours and days are characterized by ups and downs of migraines. A temporary improvement can be achieved by continually taking painkillers and triptans, but the effect becomes less and less and lasts shorter and shorter. Freedom from pain is no longer achieved; only the pain peaks can be cut. The pain pattern becomes less and less clear, the pain-free times are continuously decreasing, the pain often occurs early in the morning while sleeping, the resistance to the migraine becomes increasingly less, the mood is depressed, the pain increases irritability, tension, lack of energy, the drive and performance are reduced more and more. At some point the moment comes when nothing helps anymore. And again all that's left is the bed and the hope that the migraine will go away on its own at some point. But even this attack doesn't go away after three days; attrition, hopelessness and resignation increase.
Therapy of status migraenosus
Depending on the type of status migraenosus, different treatment options come into question.
prevention
Menstrual-associated status migraenosus is a predictable event that is therefore amenable to targeted preventive measures. If there is no migraine with aura, you can try to compensate for the drop in hormones that triggers this migraine attack by administering hormones. This is easiest for women who are already using hormonal contraception with a combination preparation of estrogen and progestin. Instead of pausing the “pill” for seven days every three weeks, you take it as a long cycle over 3 x 21 days or 6 x 21 days. The period and therefore the menstruation-associated migraines only occur every three or six months. An alternative concept without the use of hormones involves taking a long-acting triptan such as Naratriptan or Frovatriptan or the long-acting painkiller naproxen as a preventive measure in the morning and evening for a week. Treatment begins two days before the expected onset of menstruation-associated status migraenosus. This concept can only be used if there are hardly any headaches requiring treatment in the remaining cycle time and the risk of developing a headache due to medication overuse is therefore low.
If status migraenosus occurs regardless of the menstrual time window, all usual drug and non-drug options for migraine prevention can be considered. The aim of migraine prevention is not only to reduce the frequency of migraines and the intensity of pain, but also to reduce the duration of attacks.
Another option for preventing status migraenosus is to primarily avoid recurring headaches. Especially when triptans are administered alone, recurring headaches can be observed in 25 to 50% of attacks, depending on the substance. This rate can be reduced if the long-acting anti-inflammatory painkiller naproxen is taken at the beginning of the migraine attack at the same time as the relatively short-acting triptan.
Acute treatment
Preventive measures come too late if status migraenosus has already occurred. Experience shows that taking triptans and/or painkillers in status migraenosus is less and less effective every day and instead of stopping the migraine, the medication only prolongs the attack. Therefore, the general recommendation is to avoid painkillers and triptans from the fourth day of a migraine. Even if you can't imagine the quickest way to get out of status migraenosus, it is no longer necessary to take acute medication such as painkillers or triptans that you have already taken before. Anti-nausea medications are more effective. The over-the-counter dimenhydrinate, known under the trade name Vomex ® A, now offers the advantage over MCP of an additional slightly drowsy effect. This so-called sedating effect can also be achieved with weakly effective neuroleptics such as promethazine or melperone, and with tricyclic antidepressants such as amitriptyline, doxepin or trimipramine. In exceptional cases, a sedative such as diazepam can also be considered, but these should be used very cautiously because of the possible problems with getting used to it. The substances all require a prescription. The ultimate goal is to enable the person affected to keep the pain away from consciousness through a pain-distancing effect without having to take a painkiller or a triptan. Fatigue and bed rest must be taken into account. Understandably, the ability to work is not achieved in this phase. The alternative use of triptans or painkillers in this situation with the aim of wanting to function quickly leads to medication overuse and is not a sustainable solution.
Another therapeutic approach is to block the inflammation in the blood vessels of the meninges that underlies migraine pain by administering prednisolone or other cortisone preparations and thus remove the biological basis of the pain. In an emergency situation, the cortisone is usually administered intravenously, which offers the advantage of a relatively quick onset of action while avoiding absorption in the gastrointestinal area. For many of those affected, taking prednisolone 50 to 100 mg as a tablet leads to improvement within an acceptable period of time. If necessary, the morning intake can be repeated for two or three days until the inflammation subsides completely. Prednisolone also requires a prescription.
However, individual advice and examination is always necessary. The respective course and the seizure pattern must be analyzed. Preventative measures must be optimized. These include behavior and, if necessary, medication. The latter can usually only have a targeted and tolerable effect if they are used appropriately. The same applies here: knowledge is the best medicine.
Dr.
Katja Heinze-Kuhn, Dr. Axel Heinze, Prof. Dr. Hartmut Göbel Neurological-Behavioral Medicine Pain Clinic Kiel
As a sufferer, I couldn't have described the chronic migraines better during menstruation, but also when medication is overused. Word for word, that's how it happens for me too. The only thing that surprises me is that when I describe my pain attacks in exactly the same way to neurologists and pain therapists, I always get the impression that they can't do anything with it. I still have the feeling that my pain experiences are different than those of other sufferers.
I also think it's a shame that you have to read about many therapy attempts yourself (including those described in this article) and then convince your doctor to give them a try. Actually, in my opinion it should be the other way around.
I have chronic migraines that currently last up to 20 days a month and usually take significantly more than 10 triptans.
Hello,
I have almost only had aura without headaches for a year now, with speech problems, weakness on one side from head to toe that constantly changes sides, basically jumping back and forth. Also pins and needles, mainly on the face. For me these auras regularly last at least 1 week! Luckily everything went away again. I also had to jump back and forth for three weeks in a row with severe pain. I usually have cap-like pressure on my head at the end of the week. I had an MRI twice, and the cerebrospinal fluid and long-term EEG are also OK so far. I just really wanted to get rid of the fact that, like mine, there are so-called prolonged auras and that such a long aura is not immediately a migranous infarction like in the diagram. I would be very happy to receive comments from a technical perspective. I am very desperate and no longer able to work.
I recently had a similarly bad experience of recurring migraines within 5 days. I took 25 mg sumatriptan (suppositories) a total of 4 times, whatever helped. I otherwise very, very rarely take triptans and often get my migraine under control with 10-minute contrast showers.
Question: During cataract surgery I was given propofol as sedation on both eyes and then I always got severe migraines on the following day or even the day after, most recently the one described above.
Could this be the effects of propofol?
Greetings
Anna Schmitz
I was in the pain clinic in December 2015 and am infinitely grateful to all the staff and to Professor Göbel that I have fewer attacks and am able to endure the tension headaches even without painkillers.
They often disappear within a few hours. This is a wonderful experience after years of taking painkillers. The migraines currently only come 2-3 times a month, but sometimes 3-4 days. I usually don't take any painkillers on the first day and sometimes none on the last day either, so my medication days have been significantly reduced. Many thanks to Prof. Göbel for his support and empathy. My 11-hour working days (including 4 hours of driving time) on the Baltic Sea are no longer quite as hard for me; I can still manage it twice a week.
Thank you, thank you, thank you, I hope it stays that way!
LG Elena
I read your report with interest, I too have been suffering from hormonal migraines for around 20 years and now only after many and long experiments, for example. Currently only Vomex because it makes you so tired. I also take hormone gel about 4 days before my period starts, which I then take for a total of about 10 days. Would it perhaps help to take additional prednisolone or is that not recommended? LG
I was in the pain clinic last month for, among other things, an almost daily medication overuse headache. In the clinic I had a violent attack, which I survived without painkillers but with Vomex and Melperon. I have just completed the 4-week medication break and so far have only had the attack in the clinic and 2 days at home, the remaining days pain-free, without triptans etc. Thank you for the Kiel Pain Clinic, I look to the future with confidence !!
Thanks for the information.
For me, acute treatment for status migraenosus helps: Vomex, but diazepam is better. Don't go to work, stay in bed, darken.
Take as prophylaxis: gabapentin, topiramate and venlalexin.
Had about 20 attacks in January, I'm currently at about 8.
Greetings Alex Rochmann
Thank you for this interesting article. I also have recurring attacks every day (sometimes for more than 10 days in a row), but the triptan helps me within 2-3 hours and the migraine doesn't come back until the next morning. I'm fit for the day and have no pain. Is this also a medication-dependent migraine even though the medication banishes the pain for about 20 hours?