Even with good migraine care and careful management of your daily activities, you may find yourself having a migraine attack that goes on for a long time and is difficult to treat.

When you are having a migraine attack, probably the most reassuring thing to hold on to is knowing it will soon end. This is easiest to predict when you have a reliable treatment plan or a consistent attack pattern.  However, when there seems to be no end to a migraine attack, it can become especially painful, debilitating and worrying.

Migraine attacks usually last between four hours and 72 hours, without treatment. This is irrespective of the type of migraine.

However, when an attack goes beyond 72 hours, it is known as status migrainosus, referring to an unremitting, continuous attack and some people will have such attacks which might last several weeks or more. There are a few exceptions such as vestibular migraine, where the vestibular symptoms typically persist or are ongoing. Having chronic migraine or problems with medication overuse may increase the chances of having status migrainosus.

Migraine stages

Usually, an attack will start with the premonitory or prodrome phase which can last several hours or a day, followed by aura (for some) or the pain phase. It is typical for the pain to ease or clear completely and then many people are left with a period of neck stiffness, fatigue and tiredness for several hours or a few days (postdrome). It can therefore be a real struggle with ongoing pain and symptoms when the attacks do not stop despite treatment, and you wonder what can be done to end the attack.

Symptoms

The symptoms of prolonged migraine are the same as typical migraine attacks and although each person might have a unique pattern, these may include:

Throbbing pain, sensitivity to light/noise/smells/movement, scalp and skin tenderness, fatigue, irritability, cognitive problems (such as difficulty concentrating or finding words), dizziness, vertigo, aura.

Treating and preventing prolonged migraine attacks

Receiving the right treatment early is key to successfully terminating these attacks. However, the length of an attack does not necessarily change what acute treatments should be used. If your regular acute treatments are not working (triptans, non-steroidal anti-inflammatory drugs (NSAIDS), and anti-nausea medications), you may have to see your doctor or in some cases, reluctantly go to the emergency department.  You may also contact your headache specialist team for advice (if applicable).

The aim is to find a treatment that stops the attack completely to reduce the chances of it returning.

You may be offered a triptan that is faster acting such as a nasal spray or injection form, combined with simple analgesics or NSAIDs and anti-nausea medication, to take for a few days.

Clinics may offer a nerve block such as greater occipital nerve (GON) block injections.

In hospital or the A&E department, they may offer intravenous (IV) fluids for hydration, steroids or IV anti-nausea treatment such as procloperazine. Some emergency departments may offer IV NSAID such as ketorolac or aspirin. Opioids (such as morphine) have at times been used intravenously, which can encourage sleep and might help terminate an attack, although the use of opiates is not ideal in migraine because of the risk of dependency.

In some hospitals, they may offer IV dihydroergotamine or IV steroids, although these should not be used often and will not be suitable for everyone.

Non – Drug options

• A non-invasive device designed to treat migraine, if available. These devices have the advantage of frequent use without the risk of medication overuse headache and may provide additional relief when used in combination with medication treatments.
• Blue light blocking on screens
• Regular bedtime and awake times
• Healthy eating and not skipping meals
• Regular exercise and relaxation
• Minimising stress

Medication overuse headache

Medication overuse headache is sometimes referred to as rebound headache. It is a persistent headache that develops over time, as painkillers or acute treatment gradually get used more frequently until they become a part of the problem by causing more headache. It is sometimes hard to imagine that the same treatment that is giving temporary relief is making the problem worse, especially since the treatment is only being used out of necessity. Nevertheless, acute treatments work best when used on a limited number of days. When more is needed, a treatment review should be sought to find better longer-term options such as prevention.

Preventing prolonged migraine

When migraine attacks and associated disability is prolonged, a preventive may be needed even if the attacks are not frequent, due to the impact it will have on your ability to function when they occur.  A review with your doctor and a referral to a neurologist or specialist headache clinic may be required. There are well-tolerated treatments, available only from specialists, that can effectively treat prolonged attacks. These treatments include calcitonin gene-related peptide (CGRP) monoclonal antibodies and Botox.

Outlook

Migraine attacks are painful and troublesome to experience and status migrainosus is even tougher to cope with.  However, there are several treatment options to break this cycle although no single treatment that works in all situations. Therefore, it will be important to find a specialist to review your individual situation and offer appropriate treatments. In addition, this will work best when applying good non-drug strategies.