EDITORIAL

Status Migrainosus
One of the Most Poorly Understood but Important Complications of Migraine
Serena L. Orr, MD, MSc, FRCPC Correspondence
Dr. Orr
®
Neurology 2023;100:107-108. doi:10.1212/WNL.0000000000201477 serena.orr@medportal.ca

Migraine is the second most common and disabling disease worldwide,1 and some of the RELATED ARTICLE
associated disability can be attributed to complications of the disease. Status migrainosus,
Research Article
whereby an attack exceeds 72 hours in duration,2 is a complication of migraine that has
Incidence of Status
historically been very understudied. It is unclear how common it is, given limited data, but the
Migrainosus in Olmsted
few existing prevalence studies have estimated that anywhere from 3% to 20% of people with
County, Minnesota, United
migraine may experience status migrainosus.3-5 What little evidence is available suggests that it
States: Characterization
is a considerable public health problem; it is associated with significant disability,5 and people and Predictors of
with status migrainosus have a worse migraine prognosis5 and a higher risk of suicide6 when Recurrence
compared with people with migraine who do not experience status migrainosus. People with
Page 114
status migrainosus are also frequently hospitalized for management,4,5 and admissions are
incredibly costly, with estimates varying between ;USD $3,800 and 7,000 per admission.7,8
Unfortunately, existing inpatient therapies have very low levels of evidence to support their use
and may have low efficacy rates.9

The limited knowledge that exists around status migrainosus impedes advancements in de-
veloping effective interventions for this disabling migraine complication. In this issue of
Neurology®, VanderPluym et al.10 report on a population-based study of care-seeking people in
Olmsted county, Minnesota, which aims to estimate the incidence of status migrainosus, to
define this population, and to estimate recurrence rates and factors associated with recurrence.
The authors used the Rochester Epidemiology Project database, which comprises all billing
data from the Olmsted country region, to identify people with a first physician encounter
associated with a diagnosis of status migrainosus, ascertained using International Classification
of Headache Disorders criteria.2 The study population was followed up for a 1-year period after
the index physician encounter such that recurrent cases of status migrainosus and final di-
agnoses at the last follow-up could be ascertained. Data from the physician encounters were
extracted to identify possible status migrainosus recurrence triggers, attack characteristics, and
treatments used. Using these methods, the authors estimated an age-adjusted and sex-adjusted
incidence rate of 26.2/100,000 person-years for the Olmsted county during the study period
(2012–2017) and identified that peak incidence occurs between ages of 40 and 49 years and
that female individuals have a substantially higher incidence rate (46.97 vs 6.23/100,000
person-year). The authors were also able to estimate a recurrence rate: they found that 14.8% of
incident cases presented back to care for status migrainosus within 1 year, at a mean of 58 days
from the index encounter. Although it seemed that most of the cases (67.1%) did not have a
recorded trigger for their index attack, the authors identified that excessive or insufficient sleep
may be a risk factor for 1-year status migrainosus recurrence using survival models that con-
trolled for age and sex. Of interest, individuals with episodic migraine (<15 headache d/mo)2 at
their index visit were more likely to progress to chronic migraine (>15 headache d/mo, 8 of
which meet migraine criteria)2 if they experienced status migrainosus recurrence within the
1-year follow-up period (23.1% vs 7.4%).

This work makes important contributions to the field because it is the first truly population-
based study of people seeking care for status migrainosus to provide age-adjusted and sex-
adjusted estimates of the incidence rate, an estimate of the recurrence rate, and other

From the Departments of Pediatrics (S.L.O.), Community Health Sciences, and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and Section of
Neurology (S.L.O.), Alberta Children’s Hospital, Calgary, Canada.

Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Copyright © 2022 American Academy of Neurology 107

Copyright © 2022 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
 exploratory data on what may trigger recurrence and what the
prognosis of people with status migrainosus looks like over a
1-year follow-up period. Several limitations must be noted,
including the fact that the study population was composed of
people who sought care for status migrainosus within Olms-
ted county, most of whom were White (84.4%) and females
(88.6%); the results of this study are therefore not general-
izable to the whole population of people with status migrai-
nosus, and it is likely that barriers to accessing care
contributed to the lack of diversity in the sample. These es-
timates are thus only the tip of the iceberg, and the reported
incidence rate is a gross underestimate of the actual incidence
of status migrainosus. Furthermore, the data on triggers for
recurrent status migrainosus should be interpreted as ex-
ploratory for several reasons, including the fact that the au-
thors relied on what was written in nonstandardized medical
records to identify self-reported triggers and the fact that
more than 20 models were run to identify possible triggers;
this introduces possible bias related to multiple hypothesis
testing, given that there is a high risk of type I error (i.e., false
positive) for the 1 significant association found (i.e., that
excessive/insufficient sleep may be a trigger). Finally, it is
fascinating to see the data that suggest that people with epi-
sodic migraine are significantly more likely to convert to
chronic migraine if they experience recurrence of status migrai-
nosus within a year. However, the χ 2 test run to test this asso-
ciation did not control for any important confounding variables
that could explain this association, including sex, age, or psy-
chiatric comorbidities. Therefore, this result should also be
interpreted as hypothesis generating rather than confirmatory.
This study enhances our knowledge of and draws attention to
a highly neglected but critically important topic. The fact that,
in 2022, we know so little about status migrainosus is frankly
shocking, particularly when we compare the volume of re-
search on complications of epilepsy or stroke (e.g., status
epilepticus and stroke recurrence risk) with that on the
complications of migraine. Although patients may not die of
status migrainosus, it is an incredibly disabling complication
of migraine with widespread public health implications, in-
cluding loss of productivity and high health care–related costs.
We sincerely hope that this work inspires our community to
increase the focus on status migrainosus research such that we
108 Neurology | Volume 100, Number 3 | January 17, 2023
Copyright © 2022 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
can provide better care to our patients down the road and
reduce the burden associated with this disabling migraine
complication.
Study Funding
The authors report no targeted funding.
Disclosure
S.L. Orr receives royalties from Cambridge University Press.
She serves on the editorial boards of Headache, Neurology,
and the American Migraine Foundation. She also has research
funding from the Canadian Institutes of Health Research, the
Alberta Children’s Hospital Research Institute, and the
Cumming School of Medicine. She has received speaker
honoraria from the American Headache Society for delivering
a Resident Education for Assessment and Care for Headache
(REACH) Program lecture. Go to Neurology.org/N for full
disclosures.
Publication History
Received by Neurology August 26, 2022. Accepted in final form
September 12, 2022.
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Neurology.org/N
Status Migrainosus: One of the Most Poorly Understood but Important Complications
of Migraine
Serena L. Orr
Neurology 2023;100;107-108 Published Online before print September 29, 2022
DOI 10.1212/WNL.0000000000201477

This information is current as of September 29, 2022

Updated Information & including high resolution figures, can be found at:
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References This article cites 10 articles, 0 of which you can access for free at:
http://n.neurology.org/content/100/3/107.full#ref-list-1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
All epidemiology
http://n.neurology.org/cgi/collection/all_epidemiology
All Headache
http://n.neurology.org/cgi/collection/all_headache
Incidence studies
http://n.neurology.org/cgi/collection/incidence_studies
Migraine
http://n.neurology.org/cgi/collection/migraine
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