Rethinking status migrainosus: Escalation shouldn’t wait for 72 hours

Status migrainosus (SM), defined in the International Classification of Headache Disorders, 3rd edition (ICHD-3) as a severe migraine attack lasting more than 72 hours (1), is often regarded as a complication of an unresponsive or untreated migraine attack. Yet this time-based definition may inadvertently delay escalation of care, as clinicians might wait until the 72-hour threshold is crossed before considering more aggressive interventions. Current guidelines focus primarily on initial treatment, with little structured guidance on next steps when that treatment fails beyond allowing some options to be repeated at two hours. This contrasts with current best practice recommendations advocating early intervention aimed at achieving two hours of pain freedom (2).

The current SM definition derives from older observational data, most notably Selby and Lance's publication in 1960 (n = 500), in which 22.2% of migraine attacks lasted more than 72 hours (3). However, there is no biologic rationale supporting a distinct pathophysiologic shift at the 72-hour mark.

The evolution of status epilepticus (SE) criteria offers an instructive parallel. SE definitions were revised to encourage earlier, stepwise escalation of care to reduce patient harm. Migraine management could benefit from a similar model. Rather than waiting for an arbitrary duration, clinicians might escalate care progressively when initial therapies fail, preventing central sensitization and reducing disability.

It remains unclear whether a prolonged untreated migraine attack differs from one that is refractory to evidence-based acute treatment in a patient with a previously reliable response. I propose initiating a discussion around this distinction. Defining an acutely refractory migraine attack could enhance clinical decision-making and encourage earlier escalation of care. This shift would also open avenues for research and evidence generation.

Many patients report inadequate responses even when treated according to guideline-based recommendations (4). This finding supports the notion that a subset of migraine attacks may behave differently, progressing despite treatment, even when under the 72-hour threshold. The ICHD-3 already acknowledges the concept of unsuccessful treatment in its definition of migraine without aura, which includes attacks lasting 4–72 hours when untreated or unsuccessfully treated. ¹ However, despite this recognition, little structured guidance exists for managing attacks that do not respond to previously effective treatment.

Recognizing a refractory attack, such as when a patient does not achieve relief within two hours despite prior treatment success, could prompt earlier intervention. While not a diagnostic threshold, the two-hour window reflects clinical trial endpoints and serves as a reference point for treatment expectations (2). Escalation might include additional home therapies or parenteral options, depending on severity. Standardizing this concept could support prospective research into which escalation strategies are most effective. Such evidence could inform clinical pathways akin to the flowcharts used in seizure management – combining stratified care with stepwise escalation based on response.

This discussion is especially relevant for patients with chronic migraine, particularly those with continuous or near-daily headaches. In this group, distinguishing between baseline fluctuations and discrete SM attacks is often difficult. The absence of clear SM definitions for this population, who may be at higher risk, creates uncertainty around when and how to escalate care.

Furthermore, the current migraine and SM criteria focus narrowly on the headache phase, overlooking other clinically disabling components such as the premonitory or postdrome phases. Patients often report significant impairment during these periods, and emerging evidence supports treatment even before headache onset. For example, a recent phase 3 study suggests gepants may be effective during the prodrome (5). Should the duration of a migraine attack – and, by extension, SM – be redefined to include these non-headache phases? Broadening the scope may provide a more accurate framework for diagnosis and management, and supports a shift in how we conceptualize the goals of acute treatment and when escalation should occur.

In summary, I urge the headache community to critically re-examine the concept of SM. This letter is not a suggestion for immediate changes to the ICHD-3, but rather an invitation to initiate discussion and research into how we define and manage acutely refractory migraine attacks. While the 72-hour threshold currently defines SM, the absence of structured treatment escalation leaves clinicians uncertain about when and how to progress care. A refractoriness-based approach could provide a more actionable clinical framework. A Delphi consensus process may be a valuable next step to gather expert and multidisciplinary perspectives. Although there may be clinical overlap between prolonged and refractory attacks, distinguishing these concepts could improve care by clarifying when escalation is warranted and supporting the development of stepwise pathways. This approach would better align with real-world practice, empower earlier action, and foster research into targeted acute management strategies.