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Three Part Question

In [adult patients with benign headache presenting to emergency department] does [adding dexamethasone to standard analgesic therapy]reduce [recurrence]

Clinical Scenario

A 42 year old woman presents to the emergency department with gradually progressive worsening of headache over 48hours refractory to analgesics.She is known to suffer from migraines and says that she has had increasing frequency of episodes recently and her pain is similar to her migrainous episodes.She has had CT scans lately which haven't shown any abnormality.You diagnose her to be suffering from severe migraine and treat her with parenteral Imigran (sumatriptan) and metocloparamide which makes her pain better.You have heard somewhere that using dexamethasone reduces the frequency of migraine episodes.You wish to know the evidence for it.

Search Strategy

MEDLINE using OVID interface 1966-2005
Cochrane Database of Systematic Reviews
[exp DEXAMETHASONE ISONICOTINATE/ or exp DEXAMETHASONE/ or dexamethasone.mp]
AND
[headache.mp. or exp HEADACHE/ or exp TENSION HEADACHE/ or exp CLUSTER HEADACHE/ or exp HEADACHE DISORDERS/ or
exp COMMON MIGRAINE/ or migraine.mp. or exp CLASSIC MIGRAINE/ or exp MIGRAINE/]AND [exp RECURRENCE/ or recurrence.mp]

Search Outcome

No studies on the cochrane database found.9 studies found on MEDLINE out of which 1 was closely associated with the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Krymchantowski AV. Barbosa JS 2001 Sep. Brazil	23 patients, 17 women and 6 men with migraine according to IHS criteria were prospectively studied.Patients had to treat 6 consecutive attacks with usual combination taken and added dexamethasone in oral form	interventional study	recurrence defined as attack within 24hours	1 male and 1 female presented with recurrence in 3 out of 6 attacks,18 reported 1 or 2 recurrences out of 6 attacks	presumably a pilot study but very poorly conducted and does not tell us anything,no control population used,compared with the same patient's previous episodes,no blinding,very small sample, heterogeneity in the combination of medications not explored
			vomiting episodes	no one had any further vomiting episodes
Baden EY,Hunter CL May 2004 USA	57 Patients presenting to 2 emergency departments with benign headache who were evaluated and treated by the attending physician and then administered intravenous dexamethasone or saline prior to discharge(31 with dexamethasone and 24 with saline)	(SAEM annual meeting abstract 2004)prospective randomised controlled double blind placebo controlled trial	Recurrence defined as headache at 48 to 72 hours after discharge	9.7% in treatment group and 58.3% in placebo had a recurrence,p=0.001	small sample size,presented as conference abstract,unable to assess the full methodologic quality of the trial
			headache persisting at follow-up	12.9% in dexamethasone group had severe headache at follow-up and 87.1% mild headache,33.3% in placebo group had severe and 66.7% mild in saline group,p=0.136

Comment(s)

Dexamethasone has been tried in the past as an abortive therapy for migraine attacks with not much effect.A study by Gallagher in 1986 reported some benefit but the trial had methodological flaws.Dexamethasone suppression test has been used in patients with chronic headache and endogenous depression.The addition to standard migraine therapy has not been addressed before.Neurohumoral and neuroendocrine pathophysiology of migraine continues to be a grey area.Whether steroid use has any benefit to prevent recurrence by effect on ACTH secretion is not known.Baden and Hunter's abstract seems interesting and further large studies may help answer the question.

Clinical Bottom Line

Future trials may help answer the question

References

1. Krymchantowski AV. Barbosa JS Dexamethasone decreases migraine recurrence observed after treatment with a triptan combined with a nonsteroidal anti-inflammatory drug. Arquivos de Neuro-Psiquiatria. 59(3-B):708-11, 2001 Sep.
2. Baden EY,Hunter CL Intravenous dexamethasone to prevent recurrence of benign headache following discharge from the Emergency Department:A randomised,placebo controlled trial SAEM annual meeting abstract in Academic Emergency Medicine May 2004