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Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361

Singh A, et al. 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. Academic Emergency Medicine. 2008; 15(12): 1223-33

Efficacy Endpoints

Recurrence of migraine between 24 and 72 hrs of leaving the Emergency Department

Harm Endpoints

Adverse drug events

Narrative

Migraine is a common entity and is usually successfully treated in outpatient and inpatient environments. Recurrence of headache within two days following successful termination of migraine is reportedly as high as 50%, and up to 10% of patients treated in emergency departments will return for this ‘rebound’ headache.

This review summarizes available data on the use of steroids to reduce migraine recurrence. It includes 738 patients in 7 studies. Dexamethasone was more effective than placebo in reducing recurrence rates (relative risk 0.74, 95% confidence interval 0.60 to 0.90), despite being no better than placebo for the acute migraine.

Included studies were considered high quality and there was no significant heterogeneity between them. All studies (except Baden 2006) used the International Headache Society Classification criteria to diagnose migraine and all were conducted in the emergency department setting where the migraine was initially treated with standard abortive treatment.

All trials (except Fiesseler 2006) tracked adverse events to some extent though significant differences were identified in only two of these: dizziness was more common (NNH=38) while nausea was less common (NNT = 16).

The reviews in question were published prior to one recent trial1, which found similar results (NNT of 10).

Caveats

All trials used a single dose of between 10mg and 24mg dexamethasone given intravenously, and methods were reasonably standardized. Most subjects were emergency department patients who met International Headache Society criteria for migraine, and all trials appear to be of moderate to high quality. These points argue in favor of the general validity of the results as published, and a second systematic review by a different author group (using the same studies with the exception of one) came to identical conclusions qualitatively and quantitatively.

The most important limitation to this review is its limited power, with <1000 migraine patients. Indeed only one of the individual studies showed a statistically significant benefit. The methodologic rigor of the studies and the similar conclusions of two separate author groups, however, argue in favor of the aggregated results being valid. Despite this a high quality randomized trial properly powered to detect even small potential differences would be a helpful addition to this database.

Author

Andy Neil, MD

Published/Updated

September 8, 2011