Preventive treatment status among adults presenting with status migrainosus: a retrospective emergency department cohort study

Background: Status migrainosus (SM) is a disabling migraine complication that remains poorly characterized in emergency settings, particularly regarding prevention at presentation. We aimed to characterize documented preventive-treatment status among adults presenting to the emergency department (ED) with SM and explore associated baseline clinical characteristics. Methods: We conducted a single-center retrospective cohort study of adults with International Classification of Headache Disorders, 3rd edition (ICHD-3)-defined SM between January 2017 and August 2025. The screening frame comprised 1426 migraine-coded ED discharges; all 19 SM-coded encounters and 187 predefined high-suspicion encounters underwent manual chart review. The first confirmed SM presentation was the index presentation. Between-group comparisons were exploratory, with Benjamini-Hochberg false discovery rate (FDR) correction across 24 comparisons as a sensitivity analysis. Results: Forty-two patients met ICHD-3 criteria and accounted for 65 SM-related ED presentations. At index presentation, 10/42 (23.8%; exact 95% confidence interval 12.1–39.5%) had documented ongoing preventive therapy and 32/42 (76.2%) did not. Patients presenting despite preventive therapy had nominally higher rates of chronic migraine (62.5% vs. 10.0%, p = 0.009), anxiety disorders (40.0% vs. 6.2%, p = 0.021), chronic pain comorbidity (30.0% vs. 3.1%, p = 0.036), selective serotonin reuptake inhibitor use (40.0% vs. 6.5%, p = 0.024), and cannabis use (33.3% vs. 3.4%, p = 0.035). None remained significant after FDR correction (minimum q = 0.174). Conclusions: Most identified patients with ICHD-3-confirmed SM in this cohort were not receiving documented migraine preventive therapy. Exploratory secondary analyses identified nominal differences in several baseline clinical characteristics according to preventive-treatment status, but none remained significant after FDR correction. These findings provide a rationale for prospective investigation of the clinical significance of preventive-treatment status in SM, including whether SM occurring without prevention identifies an opportunity for preventive reassessment and whether SM occurring during prevention reflects underlying disease burden, treatment-related factors, or true preventive-treatment failure.