Washington University Emergency Medicine Journal Club- January 2024
Vignette
You are moonlighting in your community ED one weekday afternoon when you
encounter Ms. M, a 37-year-old woman with a history of chronic migraines. She is
currently taking daily Topamax, which she reports has significantly decreased the
frequency of her headaches, which now occur 4-5 times per year. She reports 2 days
of right-sided throbbing headache, moderate in intensity, with associated
phonophobia, photophobia, nausea, and vomiting. She tried taking rizatriptan
(Maxalt) at home without relief. She denies fevers or chills and reports that this
headache is similar to prior migraines.
Her vital signs are remarkable for mild tachycardia with no fever. She has a normal
neurologic exam and no meninigismus. She is wearing sunglasses and reports
significant photophobia with your swingling light test, but exam is otherwise
unremarkable.
You decide to treat her for a classic migraine with IV droperidol and ketorolac, as
well as a bolus of IV fluids. An hour later she reports significant improvement in her
headache and is ready to be discharged home. She requests a dose of IV steroids
before going home, “Since that’s what they gave me last time to keep me from having
another migraine.” You see in her chart that she was given 10 mg of IV
dexamethasone on a previous visit and decide to do the same, but wonder whether
the evidence supports this and what the optimal dose/route/form of IV steroid
might be most beneficial. That night, you decide to check the literature…
PICO Question
Population: Adult patients presenting to the ED with an acute migraine headache
Intervention: Administration of steroids
Comparison: Standard care, placebo
Outcome: Incidence of rebound headache in the days following ED discharge,
adverse effects, need for repeat ED visit
Search Strategy
The PubMed “Clinical Queries” tool was searched using the terms “migraine
steroids” with the therapy filter and a narrow scope, resulting in 181 citations
(http://tinyurl.com/2b76xjpn). Of these, three relevant trials and a systematic
review and meta-analysis were chosen for review.
Article 1: Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-DoseIV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454. Answer Key.
Article 2: Singh A, Alter HJ, Zaia B. 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 Dec;15(12):1223-33. Answer Key.
Article 3: Latev A, Friedman BW, Irizarry E, et al. A Randomized Trial of a Long- Acting Depot Corticosteroid Versus Dexamethasone to Prevent Headache Recurrence Among Patients With Acute Migraine Who Are Discharged From an Emergency Department. Ann Emerg Med. 2019 Feb;73(2):141-149. Answer Key.
Article 4: Friedman BW, Greenwald P, Bania TC, Esses D, Hochberg M, Solorzano C, Corbo J, Chu J, Chew E, Cheung P, Fearon S, Paternoster J, Baccellieri A, Clark S, Bijur PE, Lipton RB, Gallagher EJ. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology. 2007 Nov 27;69(22):2038-44. Answer Key.
Bottom Line
The evidence surrounding the use of steroids to prevent rebound headache in patients presenting to the ED for a migraine headache is variable, including one early study which found no significant effect on the outcome “persistent pain free” for 24 hours comparing a 10 mg dose of IV dexamethasone and placebo (OR 1.4, 95% CI 0.7 to 2.7). Notably, this study included migraines of any severity (including mild) and required patients to report no headache two hours following drug administration and over a subsequent 24-hour period. However, among a subset of patients with “moderate” or “severe” headache, “persistent headache relief” (which allowed for mild headache symptoms) was reported more often in patients receiving IV dexamethasone: OR 2.3 (95% CI 1.2 to 4.2). A systematic review and meta- analysis of early studies similarly found that among patients with a “moderate” or “severe” migraine headache, dexamethasone reduced the incidence of rebound headache within 24 to 72 hours of ED evaluation (RR 0.87, 95% CI 0.80 to 0.95; absolute risk reduction 9.7%; NNT = 10.3).
Further research comparing high-dose (16 mg) and low-dose (4 mg) IV dexamethasone found no difference in the proportion of patients achieving sustained headache relief at 48 hours (34% vs. 41%; absolute difference 7%, 95% CI
-6% to 20%). Similarly, a randomized controlled trial comparing intramuscular dexamethasone and methylprednisolone found no signiCicant difference in the mean number of days with a headache in the week after discharge (3.0 vs. 3.2 days; difference 0.4, 95% CI -0.4 to 1.1) or the the proportion of patients with sustained freedom from headache at one week (difference 4%, 95% CI -3% to 11%).
Recommendation: Based on this evidence, it is reasonable to offer patients presenting to the ED with a moderate to severe migraine headache a 4 mg dose of IV dexamethasone to decrease the likelihood of rebound headache.