Steroids for recurrent migraine headaches?

Clinical Scenario:
A young female in her 20's  with no significant medical history returns for the 3rd time this week with recurrent migraine headache.  She has had an unremarkable workup in the past including lumbar puncture and head CT.   As you start treatment with your standard migraine cocktail, you wonder if there is a way to prevent recurrence.   While you are not ready to start her on daily long term treatment such as propanolol or amitriptyline from the ED (you have given her neurology follow-up to determine if she needs this),  is there is anything you can give her now to decrease the chance that she will back yet again in the next few days?

Literature Review:
Neurogenic inflammation has been proposed to contribute to migraine recurrence and relapse.  As such, several trials have examined the potential efficacy of steroid administration in the prevention of migraine recurrence.

Based on a meta-analysis published in the British Medical Journal [1], the use of single-dose dexamethasone (range 10 -24 mg IV) compared to placebo in severe migraine headaches reduces recurrence (NNT =9) of headaches within 72 hours (relative risk 0.74, 95% confidence interval 0.60 to 0.90).  Dexamethasone does not provide significant acute pain reduction when compared to placebo (mean difference 0.37, 95% confidence interval -0.20 to 0.94) (see Figure below):

Figure 2 from Colman et. al. BMJ (2008)

In a more recent meta-analysis published in the European Journal of Neurology [2]which included 8 studies (total patients 905) - which significantly overlapped with the studies included in the BMJ study - dexamethasone (10 - 24 mg IV) was compared to placebo and again demonstrated reduction in the rate of moderate to  severe headache recurrence after 24-72 hours of headache evaluation (RR = 0.71; 95% CI = 0.59-0.86).  One study comparing PO (Prednisone 40 mg x 2 days) vs. parenteral steroids, found no statistically significant difference between the two routes of administration.
Figure 2 from Huang et. al. Eur. Journal of Neurology (2013)

Take Home Point:
-While they provide no acute pain reduction, administration of steroids in patients with frequent migraine headaches may prevent return visits in the next 24-72 hrs.

1. Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008 Jun 14;336(7657):1359-61.1.
2. Huang Y, Cai X, Song X, Tang H, Huang Y, Xie S, Hu Y. Steroids for preventing recurrence of acute severe migraine headaches: a meta-analysis. Eur J Neurol. 2013 Aug;20(8):1184-90.

Submitted by Lydia Luangruangrong, PGY-3.
Edited by  Steven Hung (@DocHungER), PGY-2 and Maia Dorsett (@maiadorsett), PGY-3
Faculty reviewed by Peter Panagos