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Migraine headache is responsible for about one third of the 5 million annual emergency department visits for headache in the U.S. Mainstay emergency therapy for migraine includes dopamine-receptor antagonists, such as metoclopramide, but the role of parenteral corticosteroids is less clear. In a randomized, double-blind, placebo-controlled trial, researchers examined the efficacy of intravenous dexamethasone as adjuvant therapy for treatment of migraine.
Two hundred five patients at four EDs received IV dexamethasone (10 mg) or placebo in addition to IV metoclopramide (20 mg) and IV diphenhydramine (25 mg). No significant differences were noted between the steroid and placebo groups in the proportions of patients who were pain free at the time of discharge, persistently pain free (pain completely resolved within 2 hours and no recurrence for 24 hours), or functionally impaired at the time of discharge. In a subgroup analysis of 45 patients who had symptoms for longer than 72 hours at the time of initial presentation, dexamethasone recipients were significantly more likely than placebo recipients to be persistently pain free (odds ratio 4.1; 95% confidence interval, 0.9–18).
Friedman BW et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology 2007 Nov 27; 69:2038.
Comment
These results are consistent with those of other studies that found no benefit from the addition of IV steroids to conventional therapy in the ED treatment of patients with migraine. Still other studies have shown some benefit from steroids in patients with status migrainosus, but at higher doses than the dose in this study. Until larger trials are conducted to investigate the role of IV steroids in the treatment of acute migraine, ED management of migraine should not change.