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Migraine: diagnosis and treatment
Published in Stephen D. Silberstein, Richard B. Upton, Peter J. Goadsby, Headache in Clinical Practice, 2018
Stephen D. Silberstein, Richard B. Upton, Peter J. Goadsby
Status migrainosus is an attack of migraine, the headache phase of which lasts more than 72 hours whether it is treated or not.8 It is characterized by the severe, persistent headache often associated with intractable nausea and vomiting. Factors responsible for triggering status migrainosus include emotional stress, depression, abuse of medications, anxiety, diet, hormonal factors, and multiple nonspecific factors.126 Status migrainosus may be secondary to an acute neurologic disorder. Prior to instituting treatment, serious organic causes of headache must be excluded.126 Patients with status migrainosus need aggressive treatment. They usually present in the emergency department, but can be treated in outpatient infusion centers. The principles of treatment for status migrainosus include: Fluid and electrolyte replacement (if indicated);Drug detoxification;Intravenous pharmacotherapy to control pain;Treatment of associated symptoms of nausea andvomiting; andConcurrent implementation of migraineprophylaxis (if indicated).
Management of a patient with unintended intravenous dihydroergotamine infusion extravasation causing brachial artery vasospasm
Published in Baylor University Medical Center Proceedings, 2023
A 40-year-old woman with a past medical history of chronic migraines was admitted for refractory status migrainosus and treated with once-daily DHE infusion for 3 days. At our institution, intravenous DHE treatments are prepared with 1 mg of DHE constituted in either 100 mL of normal saline or D5W and infused over 20 minutes. On admission, a midline (14 cm, 4 French single lumen) catheter was inserted into the patient’s right basilic vein. During her third treatment dose, the catheter infiltrated with extravasation of DHE into the adjacent soft tissue. The catheter was promptly removed without issue. The patient then reported significant sharp, stabbing pain from the midline insertion site radiating to the ulnar aspect of the right hand, associated with paresthesia and numbness of the same region. There were no reported color changes in the extremity (Figure 1). The right radial pulse remained palpable but diminished. The right ulnar pulse was difficult to palpate but evident on Doppler. Formal Doppler ultrasound of the arm revealed arterial wall thickening and moderate/severe stenosis in the proximal right brachial artery. Computed tomography angiogram showed poor contrast opacification of the distal circulation. The patient was initially managed conservatively with nitroglycerin ointment (or nitropaste) and heating pads without improvement.
Pharmacotherapy for acute migraines in children and adolescents
Published in Expert Opinion on Pharmacotherapy, 2019
P. Barbanti, L. Grazzi, G. Egeo
Dihydroergotamine (DHE) is highly effective in the acute treatment of migraine in adults, even in prolonged or intractable attacks [41]. The usefulness of IV DHE in pediatric migraine has been suggested by 2 small open-label retrospective trials of a total of 62 children and adolescents admitted to hospital for refractory migraine or status migrainosus, with a pain-free status upon discharge reported in 74.4% patients following repetitive dosing of DHE (0.1–0.5 mg per dose; on average 5–7 doses per patient) [42,43]. However, the relevance of this observation is weakened by the fact that patients had been previously treated with dopamine receptor antagonists – which exert a documented anti-migraine effect – to circumvent the development of nausea. DHE IV, at mean dose of 7–9 mg, was also reported to be helpful in relieving intractable abdominal migraine in a case series of six children [44].
Treating status migrainosus in the emergency setting: what is the best strategy?
Published in Expert Opinion on Pharmacotherapy, 2018
László Vécsei, Délia Szok, Aliz Nyári, János Tajti
The most severe manifestation of the disease is status migrainosus (SM), which is considered to be a subclass of migraine-related complications according to ICHD-3 [7]. SM equally appears in both main subcategories of migraine, i.e. migraine with and without aura [7]. By definition, SM is a debilitating migraine attack that lasts for more than 72 h and associates with devastating accompanying symptoms (e.g. nausea and vomiting). The essence of the diagnostic criteria is the following: SM can occur in patients of migraine both with or without aura, and it is typical of previous attacks except for the duration and severity of the attack. SM is often a consequence of medication overuse headache or the malpractice of acute treatment of migraine attacks [8]. The definition of medication overuse headache is based on the acute or prophylactic medication-associated headache, which occurs 15 or more days per month for three or more consecutive months [7].