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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.
[migraine.mp. OR exp Migraine Disorders OR headache.mp OR exp Headache/] AND [exp Dexamethasone/OR dexamethasone.mp.] limited to English language.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Fiesseler 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)
Colman 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
Singh et al, 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

Comment(s)

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.

Editor Comment

ED, emergency department; RR, relative risk; RCT, randomised controlled trial.

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.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. 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.
2. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence BMJ 2008;336:1359–61.
3. 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... [Erratum appears in Acad Emerg Med 2009;16:435]. Acad Emerg Med 2008;15: 1223-1233.