A case, take you to a comprehensive understanding of the status of migraine | case study

Status migrainosus (SM) refers to "debilitating migraine attacks lasting more than 72 hours", similar to "status epilepticus".

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1 Case review The patient, a 31-year-old female, had a 5-year history of migraine without aura.

After taking 10 mg of rizatriptan, the patient had migraine attacks twice a month, each lasting 1-2 hours.

Because of the non-menstrual headache that was completely similar to the previous one for 5 consecutive days, the patient suspected that it might be related to increased stress and lack of sleep, so he went to the hospital for treatment.

The patient's main complaint was systemic pain related to nausea, light and noise sensitivity, especially pulsating pain in the frontotemporal area, but without vomiting or aura.

The patient's pain intensity was 3/10 initially, and 3-8 /10 since the onset; the headache intensity was reported to be 7/10 at the time of consultation.

In the past 4 days, the patient tried rizatriptan, ibuprofen, and acetaminophen (APAP)/aspirin/caffeine combination.

Past history is negative.

Nervous system examination is normal.

The patient denied any illness or trauma.

After giving bilateral greater occipital nerve (Gon) block 3cc; bilateral ear-temporal, supraorbital and supratrochlear nerve block, each 0.
5cc, 1% lidocaine, and diclofenac sodium 50mg oral solution, the patient's headache relieved.

 Questions to ponder 1.
What is migraine status? 2.
What are the diagnostic criteria? 2 Definitions and diagnostic criteria According to the third edition of the International Classification of Headache Diseases (ICHD-3), Status migrainosus (SM) refers to "debilitating migraine attacks that last more than 72 hours" [1], similar In "status epilepticus".

Migraine is a disabling neurovascular disease, and continuous migraine attacks can cause severe disability.

This severe disability includes the inability to go to school, work, social and family activities, and even the thought of committing suicide, especially in patients who have been diagnosed with SM for more than 5 years.

SM is more common in migraine patients with or without aura.
In addition to the increase in duration and severity, its characteristics are similar to those of individuals with previous migraine attacks.

Although the diagnostic criteria for SM is that the duration of the headache attack should last more than 72 hours (see Table 1), short-term relief (less than 12 hours) caused by medication or sleep is acceptable.

The female patient in the case can be diagnosed as SM.

 Table 1 ICHD-3 SM Diagnostic Criteria Question Thinking 1.
What are the predisposing factors of SM? 2.
What are the clinical manifestations of SM? 3 Precipitating factors and clinical manifestations The predisposing factors for the onset of SM include mental stress, depression, drug abuse and withdrawal, diet, and changes in estrogen levels [2].

Menstruation is an important predisposing factor for SM [3].

SM is more likely to occur in migraine patients who are female, older, with aura, headache frequency ≥ 4 days/month, headache severity, and depression.

Studies have found that stimulation of the vestibular system can also trigger migraine attacks and SM attacks [4].

In addition, there was no significant difference in the frequency of migraine attacks before and after the onset of SM, but there was a tendency to develop chronic migraine (83.
3%).

 According to ICHD-3's diagnostic criteria for SM, except for increased severity and prolonged duration, its clinical manifestations are similar to the individual's past migraine attacks.

Studies have found that the duration of the onset of SM is 4.
8 weeks (ranging from 3-10 weeks).

In addition, patients with SM can also experience thunderous attacks, "crash-like migraine" and other manifestations different from previous migraine attacks [5].

 Questions 1.
What are the differential diagnosis of SM? The differential diagnosis of 4SM is a diagnosis of exclusion due to the nature of the diagnostic criteria for migraine, while the diagnosis of SM requires screening for the cause of secondary headaches.

According to previous reports, secondary diseases include infection or inflammation (such as abscess, fourth ventricle cysticercosis, multiple sclerosis), vascular disease (such as vertebral artery dissection, CADASIL, Sturge-Weber syndrome, pituitary stroke) and other diseases (Such as Adie's syndrome, Parry-Romberg syndrome, epilepsy with headache).

Therefore, it is necessary to conduct a rapid and systematic evaluation of the patient for the content of the differential diagnosis, including whether the patient has focal signs of neurological damage, whether there are signs of intracranial hypertension and meningeal irritation, whether there is infection, whether there are related lesions or abnormalities in imaging, etc.
.

 Questions to ponder 1.
What are the treatment strategies for SM? 5SM's treatment strategy: ➤If the patient has no special contraindications, the lost fluid should be fully replenished; ➤In principle, the sudden frustration therapy (a larger dose of drugs is used to quickly prevent the persistence of migraine symptoms, and a combination of multiple drugs is used in clinical practice.
Program), non-opioid drugs, and multi-drug combination to control seizures; ➤Establish a reasonable expectation for SM treatment in the acute phase.

The goal of treatment for patients with chronic headache is to relieve the headache to the state before the acute attack of SM.

 Treatment strategy: In the United States, there are 5 million patients who visit the emergency department for headaches each year, and nearly one-third are due to migraine attacks.

The management method of migraine should always be adjusted according to the patient's care goals, combined with consideration of the patient's current medications, medical comorbidities and contraindications of SM treatment.

A systematic review pointed out that the following four therapeutic drugs are strongly recommended: sumatriptan, prochlorperazine, metoclopramide and ketorolac as the first choice treatment in emergency departments; due to the lack of strict data and the occurrence of potentially major adverse events Possibly, this review does not recommend intravenous dexamethasone and haloperidol as treatment options in the emergency department [6].

 However, the cost of emergency care and many possible migraine irritants (fluorescent lights, loud noises, and unpleasant smells) can affect the patient's medical experience.

Therefore, ideally, the treatment of patients with severe or prolonged migraine attacks should start with outpatient treatment.

 Reasonable choice of drugs: When receiving such patients, doctors should first carefully ask the patient's headache treatment history, especially the response to various drugs, which will help guide the next treatment.

Secondly, carefully review the list of medications and current medications that patients have used before treatment to avoid adding illicit drugs or creating potentially dangerous drug combinations (such as benzodiazepines + opioids, which cause respiratory depression; topiramate + sodium valproate, Causes hyperammonemia and encephalopathy; triptolide + dihydroergotamine, causes cerebrovascular or coronary vasospasm) [7].

Furthermore, determine whether the patient has a history of opioid use or abuse; whether there is a history of untreated hypertension or cardiovascular, cerebrovascular, or peripheral vascular disease, and avoid the use of vasoconstrictor drugs (triptan, ergots) ; Triptan and ergotamine are not recommended for overlapping use within 24 hours; if the patient has a history of upper gastrointestinal ulcer or recent history of gastrointestinal bleeding, non-steroidal anti-inflammatory drugs should be avoided; if hypotension occurs, they should be taken Consider intravenous rehydration before and after drugs such as dopamine receptor antagonists and magnesium sulfate to avoid a sharp drop in blood pressure after medication.

 6 Summary SM is an acute and severe neurological disease, which requires rapid and systematic evaluation of patients.

First, if the patient's neurological examination is found to be normal, there is no danger signal in the history of headache, and the headache is similar to a previous migraine attack.

In this case, no further examination of the patient is necessary.

However, when treating patients with chronic pain (such as migraine patients), remember that patients can have secondary headaches at any time, and even attacks that meet the classic definition of SM need to be thoroughly studied.

 Second, a comprehensive grasp of the patient's headache treatment history, review of the medications and current medications and curative effects of the patients before treatment; a comprehensive understanding of the patient's past medical history, and attention to medication complications and contraindications.

 References: 1.
Headache Classification Committee of the International Headache Society (IHS).
The International Classification of Headache Disorders, 3rd edition.
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Couch JR Jr, Diamond S.
Status migrainosus: Causative and therapeutic aspects.
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Beltramone M, Donnet A.
Status migrainosus and migraine aura status in a French tertiary-care center: An 11-year retrospective analysis.
Cephalalgia.
2014;34:633-637.
4.
Robbins MS, Wang D, DeOrchis VS.
Methylprednisolone for status migrainous vertigo and cephalic status migrainosus.
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2010;50:328.
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Zhu S.
Status migrainosus.
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Accessed August 28, 2018.
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Orr SL, Aube M, Becker WJ, et al.
Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings.
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Huang Jianhua, Chen Yuzhu, Tong Fei, Li Tianjiao, Zhang Xingwen, Yu Shengyuan.
Diagnosis of persistent migraine pain and Progress in treatment strategies[J].
Chinese Journal of Pain Medicine,2021,27(01):60-63.