BET 2: Dexamethasone for reduction of migraine recurrence
Institution: St Vincent's University Hospital, Dublin, Ireland
A short-cut review was carried out to establish whether the administration of dexamethasone reduced the risk of recurrence of migraine headaches at 24 h. Three hundred and fifteen articles were found using the reported search including two systematic reviews and meta-analyses. A total of nine trials was included between the two meta-analyses. One trial was included in both analyses from the abstract data but had subsequently been published with further patient data. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated (table 2). It is concluded that the administration of dexamethasone reduces the risk of recurrence at 24 h in patients presenting to an emergency department with a migraine headache.
You have been treating a 30-year-old woman in the emergency department (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.
In [adult ED patients with migraine] is [a single dose of dexamethasone] useful to [reduce recurrence of migraine?]
Medline searched via Ovid interface.
[migraine.mp. OR exp Migraine Disorders OR headache.mp OR exp Headache/] AND [exp Dexamethasone/OR dexamethasone.mp.] limited to English language.
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.
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.
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.
Clinical 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.
▸ 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 and systematic review of the literature. [Erratum appears in Acad Emerg Med 2009;16:435]. Acad Emerg Med 2008;15:1223–33.
▸ Fiesseler FW, Shih R, Szucs P, et al. Steroids for migraine headaches: a randomized double-blind, two-armed, placebo-controlled trial. J Emerg Med 2011;40:463–8.
Provenance and peer review Commissioned; internally peer reviewed.