Dexamethasone for reduction of migraine recurrence
Date First Published:
February 10, 2012
Last Updated:
April 17, 2013
Report by:
Andrew Neill, Registrar, Emergency Medicine (St Vincents University Hospital, Dublin, Ireland)
Search checked by:
Domhnall Brannigan, St Vincents University Hospital, Dublin, Ireland
Three-Part Question:
[In adult ED patients with migraine] is [a single dose of dexamethasone] useful to [reduce recurrence of migraine?]
Clinical Scenario:
You have been treating a 30 year old woman in the ED for classic migraine. Her symptoms have improved and she is keen to go home. She was given steroids to reduce recurrence when she last visited the ED with migraine and she asks you if you are going to do the same.
Search Strategy:
Medline searched via Ovid interface.
Search Details:
[migraine.mp. OR exp Migraine Disorders OR headache.mp OR exp Headache/] AND [exp Dexamethasone/OR dexamethasone.mp.] limited to English language.
Outcome:
Search outcome: 315 papers were found. There were two published systematic reviews and meta-analyses each containing seven studies and providing a total of nine separate studies. One study, that had been included in both meta-analyses as an abstract, was published with additional included patients after the other two articles.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Steroids for migraine headaches: a randomized double-blind, two-armed, placebo-controlled trial. Fiesseler FW, Shih R, Szucs P, et al. 2011, USA | 181 Patients presenting to the ED with migraine headache. (86% classified as migraine using International Headache Society criteria). (91 patients previously published as abstract and included in meta-analyses | Double blind RCT | Recurrence of headache at 24-72 hrs | 22% recurrence in steroid group; 32% recurrence in placebo group (p=0.17) | |
| Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence Colman I, Friedman BW, Brown MD, et al. 2008, | Seven RCT with a total of 738 patients | Systematic review and meta-analysis | Recurrence of headache at 24 hrs | Reduction of recurrence on meta-analysis. RR 0.74 (95% CI 0.60 to 0.90) | Not all studies included only migraine headaches |
| 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... Singh A, Alter HJ, Zaia B. 2008, | Seven RCT with a total of 742 patients | Systematic review and meta-analysis | Recurrence of headache at 24 hrs | Reduction of recurrence. RR 0.87 (95% CI 0.80 to 0.95) | Not all studies included only migraine headaches |
Author Commentary:
Nine separate randomised controlled trials have been considered comparing dexamethasone against placebo and other agents. There is a trend towards improvement in symptoms in each of the trials although this did not always reach statistical significance. However, both meta-analyses demonstrated a modest but significant reduction in the recurrence of migraine headache at 24 h. Both meta-analyses provided a number needed to treat of nine patients.<br><br>Both systematic reviews also looked at recorded adverse events and did not find any clinically significant side effects or any significant differences in the event rates of adverse events compared to placebo. The included studies all had exclusion criteria such as pregnancy, diabetes, history of peptic ulceration etc. so this is only true of the selected population.
Bottom Line:
Patients who have received successful abortive treatment for migraine in the ED should be considered for a single does of intravenous dexamethasone before discharge to reduce the risk of recurrence, in the absence of any of the usual relative contraindications to steroid therapy.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Fiesseler FW, Shih R, Szucs P, et al.. Steroids for migraine headaches: a randomized double-blind, two-armed, placebo-controlled trial.
- Colman I, Friedman BW, Brown MD, et al.. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence
- 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...