Objective:

To systematically review the literature on status migrainosus (SM) in children and adolescents, focusing on clinical characteristics, treatment strategies, response predictors, and prognosis.

Background:

SM, described as a migraine attack lasting >72 hours, poses a significant challenge in pediatric populations. Evidence to guide management, prognostication, and prevention remains limited and fragmented.

Design/Methods:

This PRISMA-compliant review (Prospectively-registered PROSPERO ID: CRD420251088970) searched CENTRAL, MEDLINE, PubMed, Scopus, and MedRxiv using (“Status migrainosus” OR “status migrain*”) from inception to July 2025. Eligible studies included RCTs, cohorts, or case series (≥5 patients) reporting SM in individuals ≤21 years. Two independent reviewers conducted screening, extraction, and quality assessment(QA) using the Newcastle–Ottawa checklist.

Results:

Seventeen studies, encompassing 1,857 pediatric patients with SM (Total sample: 7,161), were included after screening 658 studies. Most were single-center and retrospective, limiting generalizability. Females constituted the majority (typically 70-80%), with mean ages clustering at 13-16 years. Chronic migraine(CM) at baseline was common, and psychiatric comorbidities (anxiety/depression) were frequent. Lidocaine infusions demonstrated faster pain relief than valproate but required intensive monitoring. Dihydroergotamine was effective in many cohorts, but was associated with nausea/vomiting. Nerve-blocks displayed promising short-term efficacy with fewer systemic side effects. Preventive strategies (nutraceuticals) are ineffective against recurrence. Across studies, no intervention significantly reduced short-term recurrence. Psychiatric comorbidities, ADHD, older age, medication-overuse headache, and greater baseline severity predicted poor response. Stress was a recurrent trigger for SM onset. Prognosis was guarded: two large studies reported clinical worsening after SM, and in one long-term cohort, 83% of children with episodic SM progressed to CM over 8 years. AHRQ-based-QA classified nine studies as "good", while others were "fair".

Conclusions:

Pediatric SM is characterized by female predominance, high comorbidity burden, and no unanimous treatment consensus. Predictors such as comorbidities and age highlight the need for tailored prevention. Standardized pediatric-specific protocols and randomized, controlled trials to guide management are warranted.