Redefining status migrainosus: A narrative review

OBJECTIVES: 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. BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.