LOS ANGELES—Corticosteroids can help mitigate resistant, severe, or prolonged migraine attacks, according to a systematic review presented at the 56th Annual Scientific Meeting of the American Headache Society. Corticosteroid treatment appears to reduce the severity of recurrent headaches and enable the latter to be treated with nonsteroidal therapy. Adverse events associated with corticosteroids are tolerable and mostly related to the upper gastrointestinal tract.
As many as 87% of patients with migraine who visit the emergency department have recurrent headaches within 24 hours, according to the literature. Yohannes W. Woldeamanuel, MD, postdoctoral research fellow in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine in California, and colleagues performed a systematic review and critical appraisal to assess the efficacy of corticosteroid administration in the emergency department and outpatient clinical settings on the primary outcome of reducing headache frequency. The researchers used clinical queries on PubMed and searched studies published between 1980 and the present.
Yohannes W. Woldeamanuel, MD
Most Studies Suggested That Corticosteroids Provide Benefits
The search yielded 14 studies on headache frequency reduction and eight studies on headache recurrence reduction. Of these 22 studies, 14 were methodologically rigorous (Jadad score, 5), and one was methodologically adequate (Jadad score, 3). Four studies were methodologically inadequate. Four meta-analyses also were considered. Together, the papers examined 2,203 patients with a median age of approximately 40.
Twenty-one studies suggested that corticosteroids provided benefits. Approximately 51% of the studies indicated that corticosteroids were superior to placebo, and 49% suggested that corticosteroids were noninferior to placebo. Parenteral dexamethasone was the most commonly administered corticosteroid. Approximately 65% of the studies administered the drug at a median single dose of 12.8 mg.
After administration of a corticosteroid, average reduction in headache recurrence was 30% at 24 hours and 11% at 72 hours. The numbers needed to treat were three for reduction in 24-hour headache recurrence and 10 for 72-hour headache recurrence. Patients with higher baseline disability, status migrainosus, incomplete pain relief, and previous history of headache recurrence were most likely to have a favorable outcome of corticosteroids.
A Recommendation for IV Dexamethasone
Dr. Woldeamanuel and colleagues developed several clinical practice recommendations based on their review. Neurologists should administer six to eight one-time doses of corticosteroids with a short taper per year, with an IV load of 10 mg of dexamethasone, followed by an outpatient taper for eight to 10 days, they said. A 4-mg oral dose of dexamethasone, which may be repeated in three hours, is appropriate for prolonged migraine, migraine that responds poorly to triptans or ergots, and to avoid recurrence, the authors concluded.
Administering Steroids Decreases Headache Recurrence and Frequency
The review of the results of corticosteroid treatment for severe and prolonged migraine in the emergency ward should be helpful for neurologists who treat these incapacitating headaches, according to Alan M. Rapoport, MD, Clinical Professor of Neurology at the David Geffen School of Medicine of the University of California, Los Angeles, and a coauthor of the research.
The review’s main message is that steroids in the emergency ward can decrease recurrence of the treated headache and decrease the frequency of headaches for several days after treatment, he added. “Because most studies in the review treated patients with IV dexamethasone at a median dose of 12.8 mg, the literature appears to indicate that this is the proper dose to use. From my clinical experience, I would suggest that a much smaller dose, 4 mg, given intramuscularly or subcutaneously, might work as well, although it has not been studied as carefully.
“In addition, at the New England Center for Headache in Stamford, Connecticut, Fred Sheftell, MD, and I used 4 mg of oral dexamethasone when an outpatient failed to respond adequately to the first or second day of triptan therapy,” continued Dr. Rapoport. “Our usual dose was a 4-mg tablet of dexamethasone given as soon as it was clear that a migraine headache was not responding to triptans. The dose could be repeated one time in three hours, and we limited the number of treatments to two per month. Finally, if a patient was in status migrainosus with a multiday headache, we gave 4 mg of dexamethasone three times on the first day, two times on the second day, and once on the third day, and that regime often ended the prolonged headache. I will hasten to add that this treatment was not studied scientifically, but tried clinically thousands of times over 30 years with frequent success.”
—Erik Greb