Episodic status migrainosus: One more case

To the editor:

I read with extreme interest the paper by Singh et al. (1). This study is a case series of 18 patients who had headaches characterized by attacks of migraine exclusively lasting more than 72 hours. They diagnosed these cases as “episodic status migrainosus”. Fifteen of these patients developed chronic migraine at a median of 7.8 years from their first attack.

I report a new case of episodic status migrainosus.

A 27-year-old man came to my observation with 10 years of headache attacks that lasted seven to 14 days, occurred twice every year, and were precipitated by using caffeine and stress. He never used any preventive drugs because of his low frequency of attacks.

The pain had a bilateral location, a moderate to severe intensity, a pulsating/pressing quality, and was aggravated by routine physical activity. During these attacks, he had nausea, photophobia and phonophobia. The most debilitating symptoms were pain and photophobia. Before two of these attacks, he had vertigo that lasted 60 minutes.

He used to use acetaminophen, dihydroergotamine and metoclopramide, without complete pain relief. He had no depression or anxiety disorders. Neurological examination was completely normal. Magnetic resonance imaging of the head and magnetic resonance angiography were normal.

If we use the International Classification of Headache Disorders 3 (ICHD-III beta version) criteria (2), each headache attack of our patient could be classified as status migrainosus. The diagnosis of this patient would be probable migraine. Although the patient experienced a 60-minute vertigo associated with migraine headache in two attacks, he did not meet the criteria for vestibular migraine. This would require at least five attacks.

Across the spectrum of migraine phenotypes, it is not surprising that some individuals will experience attacks either lasting less than four hours or greater than 72 hours. Singh et al. point out that a subset of patients may experience attacks exclusively lasting in excess of 72 hours with a greater than expected tendency to progress to chronic migraine.

One important concern about these cases with a low frequency of headaches is when to prescribe a preventive drug. The impact of each attack should be evaluated for this decision. If Singh et al. are right, perhaps we should consider starting preventive medication even with a low frequency of headaches.