The patient has status migrainosus and should receive repetitive intravenous infusions of dihydroergotamine. Status migrainosus is defined as a migraine attack extending beyond 72 hours and is the most common complication of acute migraine. The condition is characterized by persistent severe pain that often is accompanied by protracted nausea with vomiting and profound sensory sensitivities. Hormonal factors are extremely common as inciting events. Life stressors, mood or anxiety disorders, and acute medication overuse may be other contributing factors. Triptans are often unsuccessful in resolving a migraine of this duration, but parenteral hydration and antiemetic medications sometimes provide some relief. Because this patient has not responded to either of these treatments or to the ketorolac administered in the emergency department, the next step is repetitive administration of intravenous dihydroergotamine. This drug is administered in conjunction with either prochlorperazine or metoclopramide over the course of 1 to 3 days. Outpatient treatment options include a several-day course of oral glucocorticoids.

The patient has normal findings on neurologic examination. An MRI of the brain is unlikely to provide any additional useful information.

Combined oral contraceptives should be avoided in patients with migraine with aura because they further increase stroke risk, which is already elevated in this patient.

Opioids, such as hydromorphone, may provide analgesia but often contribute to worsening migraine frequency or intensity. They should be avoided in patients with acute migraine when other options are available.

Sertraline may help control anxiety but contributes nothing to the acute or preventive treatment of migraine and thus is inappropriate for this patient.