Abstract P675: Cardiovascular and Cerebrovascular Events in Status Migrainosus and Migraine With Aura- A National Estimate

Objective: Primary aim of this study is to compare the prevalence of vascular events [VEs - acute ischemic stroke (AIS), transient ischemic attack (TIA), acute myocardial infarction (AMI) and angina] among patients with status migrainosus and intractable migraine (SM), migraine with aura (MWA), migraine without aura (MWOA) and non-migraineurs. Secondary aim of this study is to evaluate the linkage of VEs and associated disability with different migraine subtypes. Methods: A cross-sectional study was performed using National Inpatient Sample [2016-2017] for adult hospitalizations. We extracted a cohort of secondary diagnoses of specific migraine subtypes amongst which primary diagnoses of VEs were identified using ICD 10 code. Weighted analysis using chi-square and multivariable survey logistic regression was performed to identify prevalence of VEs and evaluate relationship and disability (using APRDRG Risk Severity Score) between VEs and migraine subtypes. Results: Out of total 58,259,589 US hospitalizations, 0.1%, 0.08% and 0.03% had SM, MWA and MWOA, respectively. Prevalence of AIS (5.5 vs 0.96 vs 1.96 vs 1.71%) and TIA (3.99 vs 1.07 vs 0.49 vs 0.38%) was higher amongst MWA in comparison with SM, MWOA and non-migraineurs, respectively. (p<.0001) Prevalence of AMI was lower amongst migraineurs (SM:0.40 vs MWA:0.86 vs MWOA:0.86 vs non-migraineurs:2.15%) but prevalence of angina was higher amongst MWOA (0.01 vs 0.07 vs 0.21 vs 0.06%). (p<.0001) MWA and MWOA were associated with higher odds of AIS [MWA - aOR 3.7; 95%CI 3.4-4.1; MWOA - 1.7 (1.3-2.1)] and TIA [MWA - 11.8 (10.5-13.1); MWOA - 4.0 (2.9-5.6)] compared to non-migraineurs. Angina was associated with MWOA [3.0 (1.4-6.8)]. AIS hospitalization with SM had 52% [1.52 (1.2-1.9)] higher odds of extreme/severe disability compared to MWA. TIA patients with SM had higher odds of disability compared to MWA [3.0 (2.1-4.3)] and non-migraineurs [1.9 (1.4-2.6)]. Angina with MWOA had a significant disability [1.5 (1.04-2.2)] compared to non-migraineurs. Conclusion: SM and MWA had a significant role not only to predict AIS, TIA and angina but also increase disability. Early identification and management of these migraine subtypes may prevent VEs and mitigate disability associated with them.

Transient Splenial Lesion in New Onset Severe Persistent Daily Headache: A Clinico-radiological dilemma

Acute transient diffusion-weighted image (DWI) restriction of the splenium of corpus callosum is reported in various medical conditions (encephalopathy, hypoglycemia, in patients on antiepileptic drugs) and in various neuro-infections. We report case of a 27-year-old woman who presented with acute onset persistent severe headache for last 3 days. Her headaches were hemicranial, severe and throbbing in nature, associated with nausea and photophobia. Her symptomatology mimicked ‘status migrainosus’, however she had no history of migraine in past. She was investigated in details and her MRI brain revealed a splenial hyperintense lesion which showed spontaneous resolution on follow up. It is imperative in such cases to identify and explore the reversible causes and manage accordingly before it results in irreversible brain injury

The Association Between Hospital Length of Stay and Treatment With IV Magnesium in Patients With Status Migrainosus

Status migrainosus (SM) is a subtype of migraine defined by migraine lasting >72 hours and is difficult to treat in clinical practice. Magnesium is commonly used in the treatment of migraine. We conducted a retrospective cohort study to determine if length of admission was associated with IV magnesium therapy in patients with SM. We reviewed the charts of all patients admitted to a large military treatment facility from October 2013 to December 2018 with the admission diagnosis of migraine. There were 333 patients that were reviewed and 141 met the inclusion criteria. Nearly half of patients received IV magnesium therapy with routine care (46.8%, n = 66). IV magnesium therapy was not associated with length of admission (58 hours (IQR 25.5, 86) compared to 42 hours (IQR 25.5, 80.5) respectively, p = 0.47). Of the cases without Neurology consultation, patients who received magnesium therapy (n = 5) had numerically shorter admission but this difference did not meet statistical significance (n = 12) (17 hours (IQR 13.75, 31.25) versus 24.5 hours (IQR 15.25, 58.75), p = 0.0534). This study contributes to the limited pool of available data on the treatment of SM. Prospective research is needed to study magnesium therapy in patients with prolonged migraine.

Suspected Status Migrainosus During Flu Season

Objective: The following case report is presented to highlight the importance of maintaining a high index of suspicion for secondary causes of headache, especially during influenza season. Case Report: A 61-year-old woman with a history of infrequent episodic migraine without aura presented to our multidisciplinary pain management center during the flu season with a 1-month history of persistent and continuous headache, suspicious for status migrainosus. Imaging of the brain was obtained to rule out secondary causes of headache and was notable for findings consistent with acute rhinosinusitis. Conclusion: We discuss a case of headache secondary to acute rhinosinusitis during the flu season presenting as suspected status migrainosus. Herein, we discuss the differential diagnosis of secondary headache of 1-month duration and present the treatment options for headache secondary to acute rhinosinusitis.

Treatment and management of migraine

The chapter is a review of the possible treatment options for acute migraine. This primary headache disorder has a huge social and economic impact. The combination of a correct diagnosis, good general management and the election of the most appropriate pharmacological treatment can significantly reduce the patient’s disability. Here we provide a thorough description of the most commonly used specific (ergots and triptans) and nonspecific (analgesics, NSAIDs, dopamine antagonists, etc.) medications, as well as some of their effective combinations. We discuss how to use the different medications in relation with the clinical presentation of the migraine attacks and in special situations as status migrainosus, or refractoriness to conventional treatment. Advantages and disadvantages of the most used strategies are pointed out to assist professionals to choose the best individual treatment for their patients with acute migraine attack.

Unrecognized challenges of treating status migrainosus: An observational study

Background Status migrainosus is a condition with limited epidemiological knowledge, and no evidence-based treatment guideline or rational-driven assessment of successful treatment outcome. To fill this gap, we performed a prospective observational study in which we documented effectiveness of treatment approaches commonly used in a tertiary headache clinic. Material and methods Patients with episodic and chronic migraine who experienced continuous and prolonged attacks for more than 72 hours were treated with dexamethasone (4 mg orally twice daily for 3 days), ketorolac (60 mg intramuscularly), bilateral nerve blocks (1–2% lidocaine, 0.1–0.2 ml for both supraorbital and supratrochlear nerves, 1 ml for both auriculotemporal nerves, and 1 ml for both greater occipital nerves), or naratriptan (2.5 mg twice daily for 5 days). Hourly (for the first 24 hours) and daily (for first 30 days) change in headache intensity was documented using appropriate headache diaries. Results Fifty-four patients provided eligible data for 60 treatment attempts. The success rate of rendering patients pain free within 24 hours and maintaining the pain-free status for 48 hours was 4/13 (31%) for dexamethasone, 7/29 (24%) for nerve blocks, 1/9 (11%) for ketorolac and 1/9 (11%) for naratriptan. These success rates depended on time to remission, as the longer we allowed the treatments to begin to work and patients to become pain free (i.e. 2, 12, 24, 48, 72, or 96 hours), the more likely patients were to achieve and maintain a pain-free status for at least 48 hours. Discussion These findings suggest that current treatment approaches to terminating status migrainosus are not satisfactory and call attention to the need to develop a more scientific approach to define a treatment response for status migrainosus.