ED Management of Migraines: Steroids, you say?!

Case Presentation:

47 year old female with PMH significant for hypertension and dyslipidemia presented to the ED with the chief complaint of a 1-week history of headache. Headache was described as unilateral, localized to the left side and described as throbbing in character. It was gradual in onset; non-radiating and exacerbated by bright lights and loud noises. There was associated nausea and vomiting. It was not relieved by acetaminophen taken as an outpatient.

She describes similar episodes in the past, but all were self-resolving after 3-4 days.

She denies any recent trauma to the head. No fever, chills, neck stiffness, visual changes or focal neurological deficits. No temple tenderness or jaw claudication.

Vital signs were within normal limits on initial presentation. The CV exam was normal. On neurologic exam CN II - XII were intact, motor power was 5/5, normal sensory exam, DTRs +2. The patient had normal coordination and gait. No papilledema was noted on fundoscopic exam.

Diagnostics: CT brain w/o contrast was negative for any acute infarcts, hemorrhage or mass lesions.

The working diagnosis for the patient was migraine, and the plan was to start a migraine cocktail when the attending asks “Do you want to give her steroids as well?”

Clinical Question:

Should steroids (i.e dexamethasone) be administered in the ED management of migraines?

Summary of Evidence:

• The use of steroids in migraines is based on the rationale that the pathophysiology underlying migraines involves complex inflammatory pathways that can be mitigated by using anti-inflammatories including but not limited to steroids. (1,2)

• A meta-analysis published in 2008 showed that steroids have no role in the acute abortive management of migraine headaches (3) and consequently we don’t see their usage that often in the acute management.

• However, according to the same meta-analysis, it was shown that parenteral steroids reduce the recurrence of headaches within 72 hours when added to standard abortive therapy (3)

• This same study found no significant adverse effects between the dexamethasone vs. placebo treatment groups in terms of restlessness, tingling, or swelling. However, this study followed up adverse events (for dexamethasone) for 72h only, possibly missing delayed adverse reactions that they were not aware.

• Another study (4) looked at the impact of oral steroids (prednisone) vs. placebo in reducing the recurrence of headaches and showed that a single dose of oral prednisone did not reduce the rate of recurrence.

• However, in both studies (3) and (4) the regimens used for the acute management were not similar and we cannot tell whether that could have led to different drug-drug interactions due to the route of steroid administration. Another point to raise is that there are no studies that study the head-to-head impact of parenteral vs. oral steroids on the reduction of the recurrence.

• When it comes to dexamethasone, a systemic review (5) showed that adding it to various abortive therapies was efficacious. This leads to its generalizability in dexamethasone usage with different abortive regimens.

Recommendations:

• Even though dexamethasone has no role in the abortive treatment of migraines, it does have a role in reducing migraine recurrence within a 72h time frame and thereby decreasing patient distress and their return to the ED.

• For now, a single parenteral dexamethasone dose seems to be superior to a single oral prednisone dose. However, the literature lacks studies that compare the two regiments head-to-head and therefore more trials need to be conducted to establish significant superiority.

• Although ED physicians deal mainly with the acute management, it is imperative to consider recurrence as a significant burden of disease for the patients and for the emergency department. Based on the literature review it is reasonable to consider administering a single parenteral dose of dexamethasone in addition to abortive treatment for patients with a past medical history of recurrent migraines.

References:

1. Welch KM. Contemporary concepts of migraine pathogenesis. Neurology 2003;61:S2-8.

2. Hamel E. Current concepts of migraine pathophysiology. Can J Clin Pharmacol 1999;6(suppl A):9A-14A.

3. Colman I, Friedman BW, Brown MD et al. (2008) Parenteral dexamethasone for acute severe migraine headache: meta‐analysis of randomised controlled trials for preventing recurrence. British Medical Journal 336, 1359–61

4. Kelly AM, Kerr D, Clooney M. Impact of oral dexamethasone versus placebo after ED treatment of migraine with phenothiazines on the rate of recurrent headache: a randomised controlled trial.EmergMed J 2008;25:26-9.

5. Y. Woldeamanuel, A. Rapoport, R. Cowan. The place of corticosteroids in migraine management: a 65-year systemic review with pooled analysis and critical appraisal. Cephalalgia, 35 (11) (2015), pp. 996-1024