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Cardiology528 papers

Complicated migraine

Last edited: 4/23/2026

Overview

Complicated migraine refers to migraine attacks that are severe, prolonged, or associated with neurological symptoms beyond typical headache, potentially increasing the risk of complications such as cerebrovascular events. 1262333

Diagnosis

  • Presence of severe headache with at least one of the following: nausea, vomiting, photophobia, phonophobia.
  • Additional neurological symptoms such as focal neurological deficits, altered consciousness, or status migrainosus.
  • Exclusion of other secondary causes through neuroimaging (e.g., MRI, CT scan) when indicated. 1262333
  • Management

  • First-line treatments:
  • - Parenteral pharmacotherapies: Dexamethasone, Hydromorphone, Metoclopramide (IV formulations). 1 - CGRP receptor antagonists: Ubrogepant, Rimegepant (oral formulations). 2283049
  • Adjunctive treatments:
  • - Antiemetics for nausea. - Antihypertensives if hypertension is a concern (e.g., monitoring for hypertension with CGRP monoclonal antibodies). 431 - Non-pharmacological interventions: Acupuncture for acute attacks (evidence mixed). 4057

    Special Populations

  • Pregnancy: Caution with CGRP antagonists; limited safety data available. 27
  • Pediatrics: Triptans are generally avoided; focus on symptomatic relief with NSAIDs or antiemetics. 41
  • Elderly: Increased vigilance for comorbidities like hypertension and cerebrovascular risks; consider lower doses and monitor closely. 1531
  • Comorbidities:
  • - Hypertension: Monitor closely when using CGRP monoclonal antibodies. 431 - Patent Foramen Ovale (PFO): Consider PFO closure or antithrombotic therapy if indicated. 733

    Key Recommendations

  • Initiate parenteral therapy promptly in severe, refractory cases in the emergency department with dexamethasone, hydromorphone, and metoclopramide. (Evidence: Strong 1)
  • Consider CGRP receptor antagonists for both acute and preventive treatment, monitoring for adverse events such as hypertension. (Evidence: Moderate 2283049)
  • Evaluate and manage comorbidities like hypertension and PFO in patients with complicated migraine to mitigate stroke risk. (Evidence: Moderate 4731)
  • Exercise caution with CGRP antagonists in pregnant women due to limited safety data. (Evidence: Weak 27)
  • Avoid triptans in pediatric patients and opt for safer alternatives like NSAIDs and antiemetics for acute attacks. (Evidence: Moderate 41)
  • References

    Showing 100 most recent of 442 indexed papers.

    1 Robblee J, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2026. link 2 Pan H, Lin S. A real-world adverse events study of rimegepant from the FAERS database. Expert opinion on drug safety 2026. link 3 Chen H, Li Y. Safety analysis of gepants for migraine treatment: A pharmacovigilance study using the FDA Adverse Event Reporting System (FAERS) database. Headache 2026. link 4 Lampl C, Suliman R, Tischler-Strasser V, MaassenVanDenBrink A, Alsaadi T. Migraine Patients Treated With Erenumab and the Risk of Hypertension: A Registry-Based Real-World Study. European journal of neurology 2026. link 5 Sarıkaya C, Salkın FÖ, Sarıkaya C. P-Wave dispersion and atrial conduction abnormalities in migraine: implications for cardiovascular risk. Acta neurologica Belgica 2026. link 6 Kalapura C, Lusk JB, Wilson LE, Moore C, Yarnell S, Choudhury A et al.. Triptan Initiation and Cerebrovascular Events in Patients With Migraine: A Nationwide Cohort Study. Journal of the American Heart Association 2026. link 7 Grodzka O, Borończyk M, Zduńska A, Węgrzynek-Gallina J, Domitrz I, Lasek-Bal A. Migraine and patent foramen ovale: correlation, coexistence, dependence. A narrative review. Headache 2026. link 8 Kern M, Wischmann HA, Müller A, Kurth T, Theuring S. Sex and gender effects on incidence of migraine and stroke: a longitudinal observational study based on the german socio-economic panel. Biology of sex differences 2026. link 9 Ornello R, Caponnetto V, Ahmed F, Al-Khazali HM, Ambrosini A, Ashina S et al.. Evidence-based guidelines for the pharmacological treatment of migraine, summary version. Cephalalgia : an international journal of headache 2025. link 10 Ornello R, Caponnetto V, Ahmed F, Al-Khazali HM, Ambrosini A, Ashina S et al.. Evidence-based guidelines for the pharmacological treatment of migraine. Cephalalgia : an international journal of headache 2025. link 11 Qaseem A, Cooney TG, Etxeandia-Ikobaltzeta I, Wilt TJ, Harrod CS, Tice JA et al.. Prevention of Episodic Migraine Headache Using Pharmacologic Treatments in Outpatient Settings: A Clinical Guideline From the American College of Physicians. Annals of internal medicine 2025. link 12 Kaytser V, Hakkinen I, Dave J, Zhang P. Estimating risk of reported versus theoretical drug-drug interactions in headaches medicine: an exhaustive comparison between DrugBank and FAERS database for abortive and preventive combinations. Journal of oral & facial pain and headache 2025. link 13 Cho J, Jo H, Park J, Lee K, Lee H, Kim S et al.. Disproportionality analysis from World Health Organization data on migraine-specific medications and cerebrovascular diseases. European journal of clinical pharmacology 2025. link 14 Kim Y, Yook Y, Rhee SJ. Evaluating the association between migraine treatments and tinnitus: Insights from the US Food and Drug Administration adverse event reporting system. PloS one 2025. link 15 Zhang Y, Sun S, Wang Y. Adverse events associated with Atogepant: a FAERS-based pharmacovigilance analysis. Expert opinion on drug safety 2025. link 16 Song Q, Gao S, Tan Y. Adverse events associated with gepants: a pharmacovigilance analysis based on the FDA adverse event reporting system. The journal of headache and pain 2025. link 17 Wan X, Zhang S, Jiang C, Zhang H. Safety profile of lasmiditan: a retrospective post-marketing pharmacovigilance study based on the real-world data of FAERS database. Expert opinion on drug safety 2025. link 18 Hokama H, Sakamoto Y, Yamamoto S, Takahashi M, Kodera H, Kutsuna A et al.. Migraine-Like Headache with Aura Induced by a Small Infarct in the Parieto-Occipital Cortex: A Case Report. Journal of Nippon Medical School = Nippon Ika Daigaku zasshi 2025. link 19 Cha YH, Randall L, Weber J, Ahn S. Treatment of thoracic outlet syndrome to relieve chronic migraine. Clinical anatomy (New York, N.Y.) 2025. link 20 Yan L, Huang Y, Xie B, Liu Z, Luo L, He B et al.. Association of periodontitis and periodontal parameters with migraine and mortality in people with migraine disease: A nationally representative observational study. Headache 2025. link 21 Daghlas I, Rist PM, Chasman DI. Genetically proxied liability to migraine and risk of intracranial aneurysm and subarachnoid hemorrhage. Headache 2025. link 22 Xu T, Gao Q, Hu L, Deng B, Ren Q, Du G et al.. Causal influences of migraine on neuropsychiatric disorders: A 2-sample Mendelian randomization study. Medicine 2025. link 23 Majumdar R, Gautam P, Ghozy S, Saha R. Bilateral spontaneous vertebral artery dissection complicated by bilateral posterior cerebral artery occlusion in a migraine patient: a case report with systematic review. The International journal of neuroscience 2025. link 24 Puledda F, Sacco S, Diener HC, Ashina M, Al-Khazali HM, Ashina S et al.. International Headache Society global practice recommendations for the acute pharmacological treatment of migraine. Cephalalgia : an international journal of headache 2024. link 25 Moisset X, Demarquay G, de Gaalon S, Roos C, Donnet A, Giraud P et al.. Migraine treatment: Position paper of the French Headache Society. Revue neurologique 2024. link 26 Yeh EL, Yang CP, Lin SW, Wang HF. Feasibility of Fish Oil Supplementation on Headache Symptoms and Blood Lipids in Migraine Patients. Brain and behavior 2024. link 27 Noseda R, Bedussi F, Gobbi C, Ceschi A, Zecca C. Calcitonin gene-related peptide antagonists in pregnancy: a disproportionality analysis in VigiBase. The journal of headache and pain 2024. link 28 Cao B, Gu S, Shen Z, Zhang Y, Shen Y, Chen H. Evaluating Ubrogepant-related adverse events using the FDA adverse event reporting system. Expert opinion on drug safety 2024. link 29 Liu WH, Hu HM, Li C, Shi Q, Liu CH, Liu AX et al.. Real-world study of adverse events associated with triptan use in migraine treatment based on the U.S. Food and Drug Administration (FDA) adverse event reporting system (FAERS) database. The journal of headache and pain 2024. link 30 Hu JL, Wu JY, Xu S, Qian SY, Jiang C, Zheng GQ. Post-marketing safety concerns with rimegepant based on a pharmacovigilance study. The journal of headache and pain 2024. link 31 Guerzoni S, Castro FL, Brovia D, Baraldi C, Pani L. Evaluation of the risk of hypertension in patients treated with anti-CGRP monoclonal antibodies in a real-life study. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology 2024. link 32 Betts JW, Still JM, Lasko TA. Cryptogenic Stroke and Migraine: Using Probabilistic Independence and Machine Learning to Uncover Latent Sources of Disease from the Electronic Health Record. AMIA ... Annual Symposium proceedings. AMIA Symposium 2024. link 33 Li Z, Dong J, Yan Y, Fang F, Wang C, Zhang F et al.. Study design and rationale of COMPETE: Comparison of the effect of medication therapy in alleviating migraine with patent foramen ovale. American heart journal 2024. link 34 Espanol A, Lerebours F, Calviere L, Bonneville F, Ducros A, Larrue V et al.. Silent brain infarct in migraine: Systematic review and meta-analysis. Revue neurologique 2024. link 35 Menyhárt Á, Bálint AR, Kozák P, Bari F, Farkas E. Nimodipine accelerates the restoration of functional hyperemia during spreading oligemia. Journal of neurochemistry 2024. link 36 Zhang Y, Li Y, He L. Correlation between migraine and cerebral small vessel disease: A case-control study. European journal of pain (London, England) 2024. link 37 Sezai T, Murphy MJ, Riddell N, Nguyen V, Crewther SG. Visual Processing During the Interictal Period Between Migraines: A Meta-Analysis. Neuropsychology review 2023. link 38 Haghdoost F, Puledda F, Garcia-Azorin D, Huessler EM, Messina R, Pozo-Rosich P. Evaluating the efficacy of CGRP mAbs and gepants for the preventive treatment of migraine: A systematic review and network meta-analysis of phase 3 randomised controlled trials. Cephalalgia : an international journal of headache 2023. link 39 Carcel C, Haghdoost F, Shen J, Nanda P, Bai Y, Atkins E et al.. The effect of blood pressure lowering medications on the prevention of episodic migraine: A systematic review and meta-analysis. Cephalalgia : an international journal of headache 2023. link 40 Wang Y, Du R, Cui H, Zhang L, Yuan H, Zheng S. Acupuncture for acute migraine attacks in adults: a systematic review and meta-analysis. BMJ evidence-based medicine 2023. link 41 Chanchlani R, Agrawal A, Janjua D, Hafsa SN. The Efficacy of Different Triptans for the Treatment of Acute Headache in Pediatric Migraine: A Systematic Review. Indian pediatrics 2023. link 42 Dodick DW, Goadsby PJ, Schwedt TJ, Lipton RB, Liu C, Lu K et al.. Ubrogepant for the treatment of migraine attacks during the prodrome: a phase 3, multicentre, randomised, double-blind, placebo-controlled, crossover trial in the USA. Lancet (London, England) 2023. link01683-5) 43 Mistry H, Naghdi S, Underwood M, Duncan C, Madan J, Matharu M. Competing treatments for migraine: a headache for decision-makers. The journal of headache and pain 2023. link 44 Evers S. Cephalalgia - The early history. Cephalalgia : an international journal of headache 2023. link 45 Tuttolomondo A, Simonetta I. Molecular Research on Migraine: From Pathogenesis to Treatment. International journal of molecular sciences 2023. link 46 Shibata M. In Search of More Leaps to Realize the Precision Medicine of Migraine. International journal of molecular sciences 2023. link 47 Bahtiri L, Thomsen AV, Ashina M, Hougaard A. Migraine aura-like episodes following sclerotherapy for varicose veins of the lower extremities-A systematic review. Headache 2023. link 48 Alipouri M, Amiri E, Hoseini R, Hezarkhani LA. Effects of eight weeks of aerobic exercise and vitamin D supplementation on psychiatric comorbidities in men with migraine and vitamin D insufficiency: A randomized controlled clinical trial. Journal of affective disorders 2023. link 49 Battini V, Carnovale C, Clementi E, Sessa M. Ubrogepant and rimegepant: signal detection using spontaneous reports of adverse events from the Food and Drug Administration Adverse Event Reporting System. Expert opinion on drug safety 2023. link 50 Hensel O, Burow P, Kraya T, Stoevesandt D, Naegel S. Vertebrobasilar artery elongation in migraine-a retrospective cross-sectional study. Acta neurologica Belgica 2023. link 51 Zhang J, Mao Y, Li Y, Zhao K, Xie Q, Wang K et al.. Association between migraine or severe headache and hypertension among US adults: A cross-sectional study. Nutrition, metabolism, and cardiovascular diseases : NMCD 2023. link 52 Zhang Y, Deng Y, Zhang S, Du X, Ji Y. Systematic review and meta-analysis of a variety of chemicals to treat migraine in the neurology department. Annals of palliative medicine 2022. link 53 Sacco S, Amin FM, Ashina M, Bendtsen L, Deligianni CI, Gil-Gouveia R et al.. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention - 2022 update. The journal of headache and pain 2022. link 54 Shaterian N, Shaterian N, Ghanaatpisheh A, Abbasi F, Daniali S, Jahromi MJ et al.. Botox (OnabotulinumtoxinA) for Treatment of Migraine Symptoms: A Systematic Review. Pain research & management 2022. link 55 Varangot-Reille C, Suso-Martí L, Romero-Palau M, Suárez-Pastor P, Cuenca-Martínez F. Effects of Different Therapeutic Exercise Modalities on Migraine or Tension-Type Headache: A Systematic Review and Meta-Analysis with a Replicability Analysis. The journal of pain 2022. link 56 Singh A, Balasundaram MK. Atogepant for Migraine Prevention: A Systematic Review of Efficacy and Safety. Clinical drug investigation 2022. link 57 Yang M, Du T, Long H, Sun M, Liang F, Lao L. Acupuncture for menstrual migraine: a systematic review. BMJ supportive & palliative care 2022. link 58 Tajti J, Szok D, Nyári A, Vécsei L. CGRP and CGRP-Receptor as Targets of Migraine Therapy: Brain Prize-2021. CNS & neurological disorders drug targets 2022. link 59 Ashina M, Lanteri-Minet M, Pozo-Rosich P, Ettrup A, Christoffersen CL, Josiassen MK et al.. Safety and efficacy of eptinezumab for migraine prevention in patients with two-to-four previous preventive treatment failures (DELIVER): a multi-arm, randomised, double-blind, placebo-controlled, phase 3b trial. The Lancet. Neurology 2022. link00185-5) 60 Richer LP, Ali S, Johnson DW, Rosychuk RJ, Newton AS, Rowe BH. A randomized trial of ketorolac and metoclopramide for migraine in the emergency department. Headache 2022. link 61 Thuraiaiyah J, Kokoti L, Al-Karagholi MA, Ashina M. Involvement of adenosine signaling pathway in migraine pathophysiology: A systematic review of clinical studies. Cephalalgia : an international journal of headache 2022. link 62 Velásquez-Rimachi V, Chachaima-Mar J, Cárdenas-Baltazar EC, Loayza-Vidalon A, Morán-Mariños C, Pacheco-Barrios K et al.. Greater occipital nerve block for chronic migraine patients: A meta-analysis. Acta neurologica Scandinavica 2022. link 63 Argyriou AA, Mantovani E, Mitsikostas DD, Vikelis M, Tamburin S. A systematic review with expert opinion on the role of gepants for the preventive and abortive treatment of migraine. Expert review of neurotherapeutics 2022. link 64 Krimmel SR, Keaser ML, Speis D, Haythornthwaite JA, Seminowicz DA. Migraine disability, pain catastrophizing, and headache severity are associated with evoked pain and targeted by mind-body therapy. Pain 2022. link 65 Canpolat M, Topcu A, Kardas F, Ipekten F, Per H, Gumus H et al.. An assessment of the relation between vitamin D levels and electroencephalogram (EEG) changes in migraine patients. Bratislavske lekarske listy 2022. link 66 Liang D, Sessa M. Post-marketing safety surveillance of erenumab: new insight from Eudravigilance. Expert opinion on drug safety 2022. link 67 Arab A, Khorvash F, Kazemi M, Heidari Z, Askari G. Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on clinical, quality of life and mental health outcomes in women with migraine: a randomised controlled trial. The British journal of nutrition 2022. link 68 Rodrigues SG, Gouveia RG. Persistent monocular visual loss in migraine patients. Acta neurologica Belgica 2022. link 69 Bakırhan H, Yıldıran H, Uyar Cankay T. Associations between diet quality, DASH and Mediterranean dietary patterns and migraine characteristics. Nutritional neuroscience 2022. link 70 Khandelwal S, Meeta M, Tanvir T. Menopause hormone therapy, migraines, and thromboembolism. Best practice & research. Clinical obstetrics & gynaecology 2022. link 71 Arab A, Khorvash F, Karimi E, Heidari Z, Askari G. The effects of the dietary approaches to stop hypertension (DASH) diet on oxidative stress and clinical indices of migraine patients: a randomized controlled trial. Nutritional neuroscience 2022. link 72 Bajaj J, Doddamani R, Chandra SP, Ratre S, Parihar V, Yadav Y et al.. Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial. Neurology India 2021. link 73 Ailani J. Updates on management of headache in women and transgender women. Current opinion in neurology 2021. link 74 Rosenblum RK, Manion A. An update on practice guidelines for primary care treatment of pediatric migraine. The Nurse practitioner 2021. link 75 Wood ME, Burch RC, Hernandez-Diaz S. Polypharmacy and comorbidities during pregnancy in a cohort of women with migraine. Cephalalgia : an international journal of headache 2021. link 76 Sessa M, Andersen M. 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