WHAT’S NEW?: Earlier findings gain strength in numbers
This meta-analysis demonstrates that adjunctive therapy with a steroid is a viable option in the management of acute migraines—an intervention that each of the individual 7 RCTs was too small to justify on its own. Specifically, the addition of dexamethasone to standard migraine treatment may prevent severe recurrent pain that would otherwise necessitate a repeat visit to the ED—or to your office.
CAVEATS: Will it work in an office setting?
This meta-analysis addresses more severe headache recurrences, which are likely to lead patients to seek additional medication or repeat evaluation. Indeed, all 7 RCTs included in the evaluation were performed in an ED setting. And 6 of the 7 trials assessed dexamethasone administered parenterally, which may not be possible in some office settings. In the single trial in which the steroid was administered orally, patients were given 8 mg dexamethasone in addition to intravenous phenothiazines. In the 63 patients included in that study, the relative risk of recurrent headache was 0.69 (95% CI, 0.33-1.45). However, among those with a headache duration of <24 hours (n=40, 63.5%), the relative risk was 0.33 (95% CI, 0.11-1.05).6
Other questions: It is not clear from this single trial whether oral dexamethasone is as effective as IV administration. Nor is it clear whether other corticosteroids will work as well, as no studies of other agents have been reported.1,5 The lowest effective dose of dexamethasone is also not known.
BARRIERS TO IMPLEMENTATION: Repeat steroid use raises risk of complications
Based on this meta-analysis, it is unclear whether IV administration is required for the desired benefit. Another potential concern is associated with the administration of frequent dexamethasone boluses in patients with frequent migraines, which could lead to any one of a number of steroid-related adverse reactions, including osteonecrosis.7 The risks of steroid-related complications should be considered in using this therapy, especially for patients receiving multiple doses of dexamethasone.
Acknowledgements
The PURLs Surveillance System is supported in part by Grant Number UL1RR02499 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
