Tools for Practice


#132: Can We Stop Migraines Bound to Rebound?


CLINICAL QUESTION
Is adjunctive migraine therapy with corticosteroids helpful to decrease migraine recurrence?


BOTTOM LINE
Parenteral dexamethasone, when added to standard migraine treatment, prevents severe headache recurrence at 24-72 hours for one out of 11 patients



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EVIDENCE
  • Highest quality systematic review (published twice)1,2 reported on seven randomized control trials (RCTs) of adult emergency department (ED) patients with migraines (up to 786 patients). Patients typically received physician-chosen treatment and then one dose of intravenous dexamethasone (10-24 mg) or placebo.  
    • Severe headache recurrence 24-72 hours after discharge (interfering with activities of daily living or requiring additional physician treatment), statistically significantly reduced:  
      • 37.2% vs. 46.6% (placebo): Number Needed to Treat (NNT)=11.1  
    • Dexamethasone: 
      • Doses >15 mg not more effective than doses <15 mg.2 
      • Did not improve pain scores at ED discharge.2 
      • Systemic adverse events: Similar to placebo.2 
    • Limitations: All except one study3 from North America (primarily large EDs)most had short (≤3 day) follow up. 
  • Two other systematic reviews (less inclusive of studies4 or lower quality5had similar conclusions. 
  • Oral dexamethasoneEither as a separate small RCT3 or sub-group of a larger RCT,6 failed to decrease recurrent severe headaches (77 patients total). 
Context:  
  • Millions of Canadians7 have migraines, many patients are unsatisfied with their treatment.8 
  • Suggested pre-ED treatments include non-steroidal anti-inflammatory drugs [(NSAIDs) or acetaminophen if allergic] alone or in combination with triptans.1,9  
  • Suggested parenteral ED treatment includes: Fluids, NSAIDs, metoclopramide, and neuroleptics (prochlorperazine and chlorpromazine).1,9  
  • Variation in practices exist regarding treatment of migraines7 and over-use of narcotic analgesics have been demonstrated.10 
    • Opioids are not recommended as first- or second-line agents in migraine therapy.1,9,11 


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Author(s):

  • Michael R Kolber BSc MD CCFP MSc
  • Tina Yokota MD

1. Sumamo Schellenberg E, Dryden DM, Pasichnyk D, et al. AHRQ Publication No. 12(13)-EHC142-EF. Rockville, MD: Agency for Healthcare Research and Quality (US); 2012.

2. Colman I, Friedman BW, Brown MD, et al. BMJ. 2008; 336:1359.

3. Kelly AM, Kerr D, Clooney M. Emerg Med J. 2008; 25:26-9.

4. Huang Y, Cai X, Song X, et al. Eur J Neurol. 2013; 20(8):1184-90.

5. Singh A, Alter HJ, Zaia B. Acad Emerg Med. 2008; 15:1223-33.

6. Fiesseler FW, Shih R, Szucs P, et al. J Emerg Med. 2011; 40(4):463-8.

7. Becker WJ, Christie SN, Mackie G, et al. Can J Neurol Sci. 2010; 37:449-56.

8. Cooke LJ, Becker WJ. Can J Neurol Sci. 2010; 37:580-7.

9. Worthington I, Pringsheim T, Gawel MJ, et al. Can J Neurol Sci. 2013; 40(Suppl 3):S10-S32.

10. Loder E, Weizenbaum E, Frishberg B, et al. Headache. 2013; 53:1651-9.

11. National Opioid Use Guideline Group (NOUGG). Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain – Part B. Available at: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf Accessed September 18, 2014.

Authors do not have any conflicts of interest to declare.