Status migrainosus is a severe migraine paroxysm or a continuous series of migraine attacks lasting more than 3 days. It is characterized by a pronounced intensity of pain syndrome, repeated vomiting, weakness, hyperesthesia, adynamia. It is diagnosed on the basis of clinical criteria after the exclusion of organic brain disease using Echo-EG, EEG, REG, cerebral CT/MRI, cerebrospinal fluid analysis. It requires emergency therapy, including glucocorticosteroids, ergot pharmaceuticals, antiemetics, psychotropic drugs, blockade methods.
General information
Migraine is a common pathology, it is noted in 12-15% of the population. It occurs in the second decade of life, reaches its maximum severity by the age of 35-45. Then migraine paroxysms go down, stop by the age of 60. Women get sick 2-3 times more often than men. Status migrainosus is a complication of migraine, it is a potential danger in terms of the development of migraine stroke, therefore it requires urgent treatment in a hospital. It is observed quite rarely. There are no statistics on its exact prevalence. Pathology occurs mainly in the practice of emergency physicians, neurologists.
Causes
According to modern ideas about migraine, the disease is based on hereditary dysfunction of individual neurotransmitter systems, inadequate regulation of the tone of cerebral vessels. The status develops against the background of an uncupable migraine paroxysm. The main reasons are:
Lack of adequate therapy during the attack. Some patients do not go to the doctor, preferring to stop headache attacks with analgesics on their own. A delayed intake of the drug can provoke a status migrainosus (2 hours after the onset of paroxysm).
Insufficient effect of pharmaceuticals. In most cases, the development of the status is associated with the inefficiency of previously used antimigrenous drugs. The causes of sudden resistance to standard therapy have not been established.
Pathogenesis
Migraine attack occurs in several pathogenetic stages. Initially, the vasoconstrictor mechanism is triggered, which is replaced by vasodilation of the cerebral vessels. As a result, there is a pulsating cephalgia (headache). Vascular atony leads to perivascular edema, blood discharge into the venous system, which causes the transformation of pain syndrome into a pressing type of cephalgia. Over time, or under the action of antimigrenous drugs, the described processes acquire a reverse development, vascular tone is restored, the attack ends. If the vascular changes are pronounced, do not go away for a long time (more than 72 hours), then the paroxysm develops into a status migrainosus. In conditions of prolonged vascular dysfunction, ischemia of brain tissues develops, stroke may occur.
Symptoms
The basis of the clinical picture is intense diffuse aching cephalgia. There are periods of more severe pain (cephalgic attacks), interspersed with a temporary decrease in pain. Headache persists for more than three days, does not disappear after sleep, taking analgesic and anti-migraine drugs. Marked general weakness, adynamia, pallor is characteristic. Severe cephalgia is accompanied by repeated vomiting, as a result of which patients cannot take food, medicines. The body loses fluid and electrolytes, dehydration develops.
The patient’s condition is serious. There is an increased sensitivity to light (photophobia), sounds (hyperacusis), smells. Seizures, meningeal syndrome, general cerebral symptoms, changes in consciousness, transient visual disorders (decreased visual acuity, blurring, flickering) are possible.
Complications
The status of migraine is dangerous for the development of ischemic stroke. Migraine stroke accounts for 13.7% of ischemic cerebral lesions of young age. It proceeds covertly, according to the type of lacunar infarction. Its development can be suspected when “pulsating” (then appearing, then disappearing) focal neurological symptoms (hemianopsia, hypesthesia, facial nerve paresis) appear in the clinical picture. In patients with migraine with aura, the symptoms repeat the manifestations of aura.
Diagnostics
According to the criteria of the International Headache Society, the diagnosis of “status migrainosus” is valid if the following criteria are met:
- The clinic of a cephalgia attack corresponds to previous migraine attacks, differs in longer duration.
- Headache is characterized by significant intensity, lasting over 72 hours.
- Cephalgia is not a consequence of other diseases.
In order to confirm/refute the third criterion, an additional examination of the patient is necessary, including:
- Neurologist’s examination. It does not reveal focal neurological deficit. The presence of focal symptoms indicates the development of migraine stroke, another organic pathology of the brain.
- Echoencephalography is performed to exclude the volumetric process in the brain. Does not detect pathological changes.
- Electroencephalography. Diffuse dysrhythmia of a non-specific nature is determined, there is no epileptogenic activity.
- Rheoencephalography can diagnose asymmetric blood filling of cerebral vessels, a decrease in the tone of the carotid artery.
- Ophthalmoscopy. It is carried out by an ophthalmologist. During the status period, narrowing of the arteries and dilation of the retinal veins are determined.
- Examination of cerebrospinal fluid. Does not detect changes. It makes it possible to exclude inflammatory damage to the central nervous system, hemorrhage.
- CT, MRI of the brain . They help to make sure that there is no organic damage to the central nervous system: intracerebral hematoma, brain abscess, cerebral cyst, tumor process. With the long-term existence of migraines, foci of atrophy, ventricular expansion, and an increase in the subarachnoid space are visualized. The presence of a site of cerebral tissue ischemia allows to diagnose a migraine stroke.
- MRI of cerebral vessels is performed to exclude aneurysms, arteriovenous malformation of the brain.
It is necessary to differentiate the status migrainosus from meningitis, meningoencephalitis, subarachnoid hemorrhage. Intensive cephalgia in inflammatory diseases is accompanied by fever, general intoxication syndrome, changes in clinical blood analysis (increased ESR, leukocytosis), cerebrospinal fluid. For subarachnoid hemorrhage, a sharp headache with an increasing disorder of consciousness, the presence of blood in the cerebrospinal fluid is typical.
Treatment
Urgent hospitalization to the neurology department is indicated. The status is stopped by a combination of several methods listed below:
- The introduction of glucocorticosteroids. It is carried out intravenously using dexamethasone, prednisone. Corticosteroids have a pronounced anti-inflammatory, decongestant effect.
- The use of ergot preparations (ergotamine). Intravenous drip is performed. Pharmaceuticals of this group eliminate dilation of cerebral vessels, block neurogenic inflammation, and have a dopaminergic effect.
- Introduction of psychotropic pharmaceuticals. It is necessary to normalize the mental sphere of the patient. In accordance with clinical manifestations, antidepressants, neuroleptics, tranquilizers are prescribed.
- Relief of vomiting. It is achieved with the help of antiemetics (metoclopramide), blocking the gag reflex.
- Periosteal blockades. Performed in the trigger points of the skull arch, occiput, temporal region, cervical vertebrae. Normalize venous outflow, restore local microcirculation, reduce the excitability of local vegetative nodes, have decongestant, anti-inflammatory, analgesic effect.
- Intraosseous blockades. Are carried out with insufficient effect of periosteal. The introduction is carried out in the zygomatic bones, spinous processes of the vertebrae of the cervical spine. The effect is based on the shutdown of intraosseous receptors from the mechanism of formation of angiospastic and painful components of the attack. Thanks to the developed venous network, the injected drugs easily spread into the surrounding tissues, which provides a rapid therapeutic effect.
Prognosis and prevention
Timely emergency therapy allows you to stop the status migrainosus. Lack of treatment, incorrect therapy lead to a prolonged course of the status, exhausting the patient, the development of stroke, dehydration. The best way of prevention is adequate treatment of migraines, including intercrime therapy. Migraine sufferers are advised to always carry medications that stop paroxysms, use them at the first signs of an impending attack.
