Redefining status migrainosus: A narrative review

To critically evaluate the current International Classification of Headache Disorders, 3rd edition (ICHD-3) definition of status migrainosus (SM) and assess how well it meets clinical and research needs. The review will also explore additional attack dimensions that could support a more patient-centric and clinically actionable definition.

ICHD-3 defines SM as a debilitating migraine attack lasting more than 72 h. This 72-h threshold is historically derived rather than empirically validated, and limited evidence is available to guide treatment. We posit that a primarily duration-based definition restricts both the clinical utility of SM and its usefulness as a construct in acute treatment trials.

This narrative review was structured around five key questions: (Q1) Do we need specific diagnostic criteria for SM; (Q2) Should time be used within the definition; (Q3) Should attack severity and disability be included; (Q4) Should treatment response be included; and (Q5) Should migraine attack phases be considered. Targeted PubMed searches (inception-mid-2025) were performed for questions 2-5. One reviewer was assigned to each of these questions and independently conducted title/abstract screening, full-text review, and data extraction.

Searches yielded 36 publications from 504 screened for question 2, 12 from 322 for question 3, 61 from 171 for question 4, and 13 from 1708 for question 5. Q1: Although SM remains clinically useful, the current criteria do not capture the heterogeneity of prolonged attacks and provide limited guidance for treatment escalation. Q2: Attack duration varies widely across migraine phenotypes, and the 72-h cutoff lacks clear justification and is misaligned with real-world practice, where escalation occurs well before 72 h. Q3: "Debilitating" is undefined, and pain severity alone insufficiently reflects functional impact; disability may offer a more meaningful indicator for clinical decision-making. Q4: Treatment refractoriness is central to how prolonged attacks are managed but is not incorporated into current criteria, and standardized definitions of acute treatment failure are lacking. Q5: Prodrome, aura, and postdrome can meaningfully contribute to attack burden, yet SM criteria do not specify whether nonheadache phases count toward attack duration.

A revised definition of SM should move beyond a rigid 72-h threshold and give greater weight to functional impairment, treatment response, and more explicit definitions of attack duration that clarify how nonheadache phases are handled.