Steroids to Prevent Early Recurrence Following Migraine
Search Strategy: Reviewing Rowes’ Evidence Based Emergency Medicine (p 499) you note that no systematic reviews had been published, although seven clinical trials of dexamethasone were reported. Searching PUBMED Clinical Queries using the search term “migraine” for therapy (narrow, specific – 1098 citations) and combining the results with an unfiltered PUBMED search for “corticosteroids” you obtain 12 citations including several relevant RCTs. Finally, you conduct a PUBMED Clinical Query search for meta-analyses using the search “migraine” and then combine these results with “corticosteroids” at which point you identify two meta-analyses.
Spring must be associated with migraine headaches. At least today’s events suggest an association because you have already evaluated several cephalalgia patients and not even half your shift has expired. Nonetheless you bravely grab the next “my aching head” chart and march into the examination room where you encounter a pleasant 20-year old college female. Approximately ten hours ago she noted the gradual onset of her typical right retro-orbital pulsating headache pattern following scotomata indicating that her migraines were back for another visit. She has no other past medical history including no malignancies, polycystic disease, prior strokes or known aneurysms. She has an unremarkable head CT at age 18, about 2-years after her migraines ensued. She notes no recent head trauma nor do you note any physical evidence of occult trauma. Your physical exam is unremarkable including no evidence of jolt accentuation of the headache.
While evaluating her electronic medical record, you note that she has had three prior ED evaluations for migraine headache. Each time she has responded to intravenous dopaminergic agents, but she reports that her headaches recurred twice before following discharge from the ED. She asks whether any prescription medication might reduce the risk of headache recurrence once she is discharged.
Population: Emergency Department patients with acute migraine headache exacerbation
Intervention: Corticosteroid administration plus routine care
Comparison: Routine care plus placebo
Outcome: Post-discharge headache recurrence, functional impairment, ED recidivism, adverse drug event
First years: Intravenous dexamethasone vs. placebo as adjunctive therapy to reduce the recurrence rate of acute migraine headaches: a multicenter, double-blinded, placebo-controlled randomized clinical trial, Am J Emerg Med 2008; 26: 124-130. (http://pmid.us/18272089)
Second years: Impact of oral dexamethasone versus placebo after ED treatment of migraine with phenothiazines on the rate of recurrent headache: a randomized controlled trial, Emerg Med J 2008; 25: 26-29. (http://pmid.us/18156535)
Third years: Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature, Acad Emerg Med 2008; 15: 1223-1233. (http://pmid.us/18976336)
Article 1: Intravenous dexamethasone vs. placebo as adjunctive therapy to reduce the recurrence rate of acute migraine headaches: a multicenter, double-blinded, placebo-controlled randomized clinical trial, Am J Emerg Med 2008; 26: 124–130
Article 2: Impact of oral dexamethasone versus placebo after ED treatment of migraine with phenothiazines on the rate of recurrent headache: a randomised controlled trial, Emerg Med J 2008; 25: 26-29
Article 3: Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature, Acad Emerg Med 2008; 15: 1223–1233
Article 4: Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence, BMJ 2008; 336: 1359-1361
The Succinct Answer
In the United States, migraine-related lost productivity costs approach $17 billion annually. Despite the fact that acute migraine patients desire immediate and sustained pain relief, current Emergency Medicine guidelines do not include the use of corticosteroids to reduce the incidence of short-term rebound headache that occur in as many as half such patients. EM physicians are inconsistent in labeling headaches as migraines and employ myriad abortive therapies, including narcotics. While physicians downplay the importance of migraine recurrence, patients consider lower relapse rates to be the outcome of greatest importance in a willingness to pay model. Neurogenic inflammation may play a role in perpetuating migraine headaches. Therefore, single dose steroids following effective ED abortive therapy may provide a cheap, readily available, well-tolerated for EM.
The current evidence suggests that a single ED dose of IV or PO dexamethasone (mean 8 mg, most effective doses likely > 15 mg) in International Headache Society defined migraine headache, in conjunction with other routine abortive therapy, can diminish moderate to severe migraine recurrence within 1- to 3-days (NNT = 10) without significant side-effect risks. Future trials are needed to identify the optimal dose, as well as ED migraine patient subsets most likely to benefit from acute prophylactic therapy. Based upon currently available evidence, practice should be oral or intravenous dexamethasone at 15-24 mg doses in patients prone to migraine recurrence following effective ED abortive therapy and presenting within 24-hours of symptom onset. Remember the various exclusion criteria for these trials in whom this evidence cannot be applied: pregnancy, known peptic ulcer disease, diabetes, or systemic fungal infections. Additionally, explain to patients that up to 6% may experience transient side-effects such as dizziness or tingling that always resolved without treatment in multiple studies.